Proceedings of Workshop On India’s Health System: Role of Health Sector Reforms
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Proceedings of Workshop
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India’s Health System: Role of Health Sector Reforms - extracted text
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Proceedings of Workshop
On
India’s Health System: Role of Health Sector Reforms
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September 4-5,2003
India International Centre
New Delhi
Bureau of Planning
Directorate General of Health Services
Ministry of Health & Family Welfare
Government of India, New Delhi
(in collaboration with WHO)
CONTENTS
Topic
No
1.
Address
2.
Address
3.
Address
4.
5.
Address
Address
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Page No
Inaugural Session____________________
Smt. P Jyoti Rao, Additional Secretary (Health),
1-3
Ministry of Health & Family Welfare_________
Dr. Prema Ramachandran, Adviser (Health),
4-10
Planning Commission_____________________
Shri P. Hota, Secretary (Family Welfare,
11-12
Ministry of Health &Family Welfare_________
Dr. S. J. Habayeb, WHQ-WR, India__________
13-14
15-18
Dr. S.P. Agarwal, Director General of Health
Services
Technical Session____________________
Overview of Health Sector Dr. Rama Baru, Associate Professor, Dept, of
19-22
Reforms in India
Preventive & Social Medicine, Jawaharlal
Nehru University_________________________
Health Sector Reforms in Ms. Anjali Bhawra, Managing Director, PHSC
23-25
Punjab ________________ & Special Secretary Health_________________
Rajasthan Health
Sector Dr. B Sekhar,
26-29
Reform: A Perspective______ Special Secretary, Medical & Health________
Reforms in Health Services in Shri S. K. Nanda,
30-33
Gujarat__________________ Secretary Health__________________________
Health System Reforms in Dr. R. N. Mahanta
34-37
Himachal Pradesh__________ Nodal Officer, SSRC & Dy. Dir (H)__________
Health Sector Reforms in Dr. I.S. Pal, Director General Medical Health &
38-39
Uttaranchal_______________ Family Welfare___________________________
40-41
From First Phase to Second Ms. Nandita Chatterjee
Phase of RCH_____________ NPO (RCH), WHO
Remarks by Resource Persons
42-48
Synopsis of Day 1
Ms. Anagha Khot
49
WHO National Consultant (HSR) MOH&F W
Group Work
50-53
'______________________Concluding Remarks______
16. Shri Javid Chowdhury, Former Secretary (Health), MOH&FW
17. Smt. P. Jyoti Rao, Additional Secretary (Health), MOH&FW
54-55
Annexure
18.
19.
20.
21.
Agenda ____________
Background Paper______
Power Point Presentations
List of Participants
56-58
59-85
86-135
13^-141
INAUGURAL SESSION
Inaugural Session
Smt P Jyoti Rao
Secretary Family Welfare Shri Hota, Dr Habayeb, Shri Chowdhury, Dr. Agarwal,
Director General of Health Services, Dr. Ramachandran, Adviser Health, Planning
Commission, Ladies and Gentlemen. It gives me great pleasure to welcome you to this
workshop on India’s Health System: Role of Health Sector Reforms.; While reforms have
been on the anvil in our country, its effects have not been clearly visible. We have not as
yet, been able to crystallize our thoughts on ‘health sector reforms in the Indian context’.
The customized set of reforms for our country must be unique and should flow from our
system itself.
We need to give a very serious thought to what actually constitutes reforms in the overall
global perspective, in the Indian perspective and also in the regional perspective. I think
this conference which we are holding today perhaps should have been held ten years
earlier, when this whole talk of reforms was on. But somehow, I think we missed that
opportunity and we are doing it now. But it’s better late than never. Of course, it has its
advantages, because we have the free rider advantage, where we can make use of the
experiences of the other sectors in the implementation of the process of reform. This
therefore is one of the main objectives of this one and a half day workshop. We are very
happy to find that there is a galaxy of State government secretaries who are going to
make presentations on this subject and we hope to learn a lot from them because despite
the fact that we really don’t have a well defined strategy for reforms, some of the States
have taken initiatives and moved forward despite severe resource constraints. We all
know the constrained resource scenario in the States. Despite that there has been some
commitment in some of these areas which impinge on economic reforms. The first thing
we need to do today, is to have a brain storming session to look at what could be a
workable definition of health sector reforms, what would be our priorities, what would be
the first generation, the second generation and the third generation reforms.
Health is such a vast subject covering so many areas. Many new issues are emerging.
.Now we have telemedicine coming in, computerization which is changing the entire way
of looking at things including medicine, we also have the other very critical issues on
social side of delivery of health systems to the poor, to the below poverty line (BPL)
people. While there is some sensitivity in the system of delivery to below poverty line
persons, we really have not been able to crystallize a mechanism for the same. Even the
government delivery system unfortunately is elitist, the access is elitist and the poor
really do not get much out of it despite the fact that it is a system which is supposed to
reach out for them. So that’s one very important area which I thought I should mention
first because in this whole process of commercialization of the health sector, the concepts
at one time would be an anathema to anybody in health. Health tourism which is a very
commercial face of health, you know these kinds of concepts, I think we should not
forget the safety nets, because in any civilized reforms package, safety net for the poor
has to be a very important consideration and it has to be built into the package. Some of
these reforms are driven by the multilateral and bilateral collaborations that we have.
1
Some very interesting concepts have come in; we need to thank the World Bank for this
whole concept of user charges. This user charges is something which didn’t exist in our
lexicon, not so long ago, but today it is there, we are all very sensitive to the need of user
charges, for building a stake for the people who use the system. So these are driven by
compulsions, we have in our collaboration with multilateral and bilateral agencies. This is
one set of reforms and many good things have come out of it and they will continue to
come out of it, in so far as the concept of user charges is concerned. Of course as we
stand today, user charges as they exist in most hospitals do not go beyond the domain of
tokenism, I am sorry to be so forthright but we need to look at user charges in a much
more serious way because while we need to insulate the poor from these very high
charges, at the same time we have to see that the people who can pay are charged
rationally and are charged as per the costs actually involved in providing them that kind
of health services.
I am sure that this august gathering here today will decide what should be our priorities,
what should be the first thing that we should undertake and the timeframe that we would
set for ourselves in achieving some of these reforms. The other pre-occupation of this
workshop is documentation. We hardly have any documentation on health sector reforms.
There have been very good stories coming out from across the globe and we need to take
a closer look at such initiatives This cell which has been set up now in the Bureau of
Planning, which is looking very intensively at this subject will access all the pertinent
information on what have been the global initiatives and where and how they could apply
to our situation. The other thing is that we would also like to document the various
initiatives that have been taken by the various State governments. At the end of this, we
would also like to bring out an annotated bibliography on whatever literature that exists
on this subject so that it can be accessed by academics, health professionals and all other
stakeholders. So, these are the two primary concerns. Of course as I said, we have no
choice but to go ahead with the process of reforms. The State government and the
Government of India would for quite some time to come continue to play a dominant role
on issues of access, investments, etc. There is no way that we can wish away the role of
the State. But we envisage the role of the State with a very vibrant public private
partnership. We have to make some more efforts, to reach out to the non-governmental
organizations (NGOs), to reach out to the private sector and evolve a working mechanism
where their involvement in our health initiatives is of a very high and sensitive order.
And alongside with all of this, we will have to carry on our crusade for more share of the
investment pie in the health sector. In fact, I am sorry to share this piece of information
with you, that in the current year, the budgetary support for the Department of Health is
pegged at a level of Rs. 1550 crore. It is I would say, a tribute to the resilience of our
system that these 1550 crore are looking after hundreds of institutions, they are looking at
a myriad of disease programmes, it’s something. Sometimes, it really puzzles me as to
how we are able to stretch the rupee value so much that it can cater to so many things at
the same time. So we need to have higher investments in the health whether they flow
from the budgetary resources, or from the private sector and I think all of us in health,
need to generate a lobby for getting more funds. A Ministry like Rural Development,
where I have had the privilege to work earlier, has a budgetary allocation of Rs. 14,000
2
crore against the Department of Health getting just Rs. 1550 crore. So without
investments in health, our reforms would remain hollow. This is something, which we
would not be able to implement.
I think I have in my own way introduced the subject. We have present here today a
galaxy of knowledgeable persons in this field. I would once again, welcome you on
behalf of the Ministry and thank you for sparing your precious time, for being with us
today and we look forward to very intensive and meaningful deliberations and excellent
documentation coming out of what we discuss over the next one and a halfdays.
Thank you very much.
3
Dr. Prema Ramachandran
Thank you very much for giving me this opportunity to share with you an area of intense
interest to all health professionals and an area in which 13 working groups of the
Planning Commission for the Tenth Plan slaved. In fact, it was far easier for them to
review their programmes, talk about the future but we insisted that in every one of them
there has to be health sector reforms and what is it that has happened and how they have
fared. In a similar fashion, we had also requested all the States to keep on telling us about
what reforms they had done, what the impact, why did they do it was and how things
progressed. I must place on record, the fact that they were all extremely co-operative and
did this hard work. Very often, saying that you know we didn’t really plan out the way
we planned out, and that honest admission is in the basic of all good reform processes.
I would try to give some background on what was done in the Ninth Plan and in the
Tenth Plan Steering Committee, chaired by Secretary Health (at that time), who also did
quite a lot of heart searching and frank discussions on what is going right and what is
going wrong. Some of this has already entered into the Tenth Plan document. Lot of it is
yet to be implemented. First I would like to take on why we embarked on health system
reforms. Over the last five decades, we have built up a huge infrastructure with a large
manpower. There is always going to be resource constraint, competing claims on what is
right and what is priority, but all of us must admit that to some extent health did get its
due share. As ,a result, primary, secondary and tertiary care institutions were built, not
only in the government sector but also in the voluntary and private sector. This country
has no dearth of health manpower. In fact we now face a question of under employment
and unemployment, not only in the nursing profession but even among the doctors today.
We have produced people, their commitment and competence is not in question, by
anybody. In fact we have a significant place in many of the health systems of Middle
East, not to talk about the United Kingdom and the United States of America, where we
form a significant proportion of health care professionals. In the initial 20 years when this
hard work was going on, we were all buoyed up by the fact that mortality rates are
crumbling down; small pox has been eliminated and so on. Everybody felt good. The
problems arose in the 1990s when mortality rates started plateauing and we started facing
the dual disease burden. Along with the dual disease burden, we also had the problem of
escalating awareness about things that could be done, by the health system and the fact
that many of them are beyond what the individual or the institution at the country could
afford and th?s conflict was at the base of most of our mandate to look at reforms which
would ensure that health system provides the kind of care that it ought to.
We have a health system which consists of four major subsystems; one is the primary,
secondary and tertiary care institutions, manned by medical and paramedical personnel
who provide health services. Services are provided in the private, voluntary and public
sector. Additionally, we have medical colleges and paraprofessional training institutions
to train the needed manpower, again in private, public and voluntary sector. There are
also programme managers in the governmental sector who manage the ongoing
programmes at central, state and district levels. Theoretically, we have a two way Health
Management Information System (HMIS) system of data collection, collation, analysis
4
and response. Data collection, collation and analysis pose a problem and responses, if we
are honest, in most cases are non-existent. The major catastrophy we face is that none of
these four are linked with one another and they just do not function as a part of cohesive
single system. If an eye says I will see sometime and an ear says, I will hear sometime,
how will human being function? It is that which is creating the major problem in the
health system. As I said earlier, the initial enthusiasm that if one really improves access
by creating primary health care there will be tremendous improvement in access to
essential services, was sustained by the government investing in sub-centres (SCs),
primary health centres (PHCs), community health centres (CHCs), between 1980s and
mid 1990s. By mid 1990s, we had more or less achieved the requirements for sub-centres
and primary health Centres and if we really integrate the community health centres with
the sub-divisional hospitals and taluka hospitals, we also have achieved theoretically the
numbers that were required to cover the entire country. However, if you have a look at
the National Facility Survey done by the Department of Family Welfare, you can see that
barring Maharashtra, where about almost all the primary health centres (PHCs) had more
than 60 percent of essential basic requirement for providing minimum health services,
none of the States have those essential things without which primary health care delivery
is impossible and in this we must pay tribute to people who did this kind of survey and
came out with the reality, however much it might have displeased the people who have
been contributing to this kind of infrastructural development. Because of this survey and
its data, for the Tenth Plan we were able to say, not to have any more construction.
Whatever money, is available should be invested in ensuring that the primary health
system that exists, becomes fully functional and that is our highest priority.
The private sector also provided some inputs and over the time period, there has been an
increase in the number of hospitals in the private sector. Contrary to the popular belief,
majority of the increase in hospitals in the private sector has also been what we would
consider as primary or secondary sector. Corporate and super-specialty hospitals still
form only about 3 percent of the whole private sector hospitals. But we do have a major
paradox. Plethora of hospitals exists but very few are located in areas with high
morbidity. There is huge health manpower, there is considerable underemployment and
unemployment but still in slums of Delhi quacks practice. That is the reality. Vast sums
are spent on drugs and diagnostics, not only by the government sector but also by the
private sector. On the one side we see unused piles of drugs in some places but in many
places lack of appropriate diagnostics and drugs is the reason why many people are not
able to access good quality health care. Above all, there is still today, lack of defined
norms of care at each level and appropriate referral services. Finally, one critical thing,
we have to respect the primary health care worker. We have to assign them a unique role.
Do we give them the responsibility of acting as a gatekeeper to people accessing
secondary and tertiary care? No and on their recommendation when they do refer, are we
always honoring them? No and these are hard realities which come in the way of building
up a good referral system. As a result of this, we have a system where some hospitals are
grossly overcrowded and many are grossly underutilized.
We also have a problem of gap /mismatch between manpower and infrastructure and
availability and utilization of services are poorest in the neediest rural areas. This access
5
and utilization differences, account for the massive interstate/ inter district and urban
rural differences in health care performance. I am stressing this because investments have
been essentially similar, then why is there such great disparity in performance? That is
due to access, awareness and utilization.
So if we summarize, we have health care institutions that are reasonably staffed with
skilled staff and here I include private and voluntary sector, it is not the government
sector alone. All of them face difficulty in running their institution because there is a
change in health care needs. Further in the last ten years, the momentum of change has
been rather great and that really puts the system at a severe disadvantage for we are,
facing a change not only in the health care needs but also in the technology leading to
faster obsolescence of equipment. How can one afford to buy new equipment in a span of
five years? In the private and voluntary sector, there is a tremendous, rapid turnover of
staff, who is seeking better opportunities. All the institutions also face the conflicting
imperatives of containing costs and becoming self-sustaining. Can one shoulder social
responsibility? Is health a fundamental right and should one really be subsidizing it?
Whom would one subsidize? How will one target and how does one marry self
sustainability with social responsibility? I think these are questions that are to be honestly
addressed and some via-media answers have to be found. Last but not the least, major
medical institutions face labour and consumer litigation which is increasingly becoming
an agony for them because the system people are not trained in tackling this, they are not
managers, they are not legal experts and when they find things are going wrong they feel
demotivated and disheartened.
The health personnel are highly skilled, but I believe and I know, all of us have tribal
feelings and we tend to say, that we are the nicest and the best. But I still believe that
educationists and health professionals are usually slightly more committed to social cause
then many others. I am not saying its universal but proportions perhaps are titled towards
commitment in these sectors. They require periodic updating and that is absolutely
lacking. What I know about most things, is what I learnt 30 years ago, and the world has
turned absolutely upside down in the meanwhile. They also have a problem in having a
system for screening and referral, access to institutions with adequate staff to whom they
can farm off their patients when complications arise. Quality control systems do not exist,
and because of that how can anyone ensure that the patients get appropriate care, cost of
care is not prohibitive and physicians get protection against litigation. In many private
institutions today, Indian doctors pay about 15 percent of their packet for health
insurance, for malpractice insurance protection and that is not a very healthy trend at all,
because it will escalate the cost of care still further.
The findings of a National Sample Survey (NSS), which was later analyzed by the
National Council for Applied Economic Research (NCAER), shows that people above
poverty line (APL) and below poverty line always go to the government hospitals for
immunization services. The same government hospitals, the same queues, the same twohour wait but they know that fresh vaccines of good quality are made available and that
system does not fail. It has not failed in the last 15-20 years and therefore they access it.
And look at the other end, for out-patient care for cough, cold, fever, diahorrea; they
6c
never go to government hospitals, as they feel it is a waste of time and energy. All they
want is symptomatic relief, that they feel can be got anywhere. They are very discerning
and this is something that we have to accept and understand.
When it comes to in-patient care, there has definitely been a growth in in-patient care and
out-patient care in the private sector. But for inpatient care, majority of people still use
government hospitals, the reason is shown in the next slide. It is because the cost of care
in government hospitals even after institutionalizing all the user charges, are a fraction of
the cost for the same in private institutions. It is logical, it has to be like that because
there is so much of subsidy in the government system and therefore people are aware of it
and are using it.
People are willing and trying to invest both in public and private facilities for accessing
health care. It cuts across all, the richest to the poorest. All use government facilities, all
use private facilities. The proportion which they use is not very radically different. They
are willing to, irrespective of their income status, use their savings sell their assets and
borrow for health care. Health is definitely, therefore a valued commodity by all
segments of population. So can we not conclude from these that the people here, are
responsible, rational and increasingly aware; they might have been slow to respond
initially but once they have responded, their response is sustained and they are willing to
invest in health. But what are their concerns? Their concerns are very clearly articulated.
Diagnosis and management of illnesses are becoming increasingly complex and costly;
the trusted family physicians have vanished and the greatest of their concern is the
commercialization of health care, they fear potential for poor quality care, problem of
overuse, abuse and misuse of technology for treatment as well as diagnosis and the
exploitation of vulnerable patients because of information asymmetry. And information
asymmetry in health sector is enormous.
The health sector as a whole, faces this problem of dual disease burden of communicable
and non-communicable diseases, technological advances which widen the spectrum of
possible interventions and escalating cost of care and therefore the Ninth Plan,
emphasized that there is a need to review the response of the public, voluntary and
private sector health care providers as well as population to the changing health scenario.
The Department of Health & Family Welfare and the National Sample Survey
Organisation (NSSO) conducted many of the surveys in response to this first mandate
that was given. The second was to reorganize and restructure health services so that they
function as an integral component of an efficient and effective multi-professional health
system. Third was to introduce health system reforms to enable the population to obtain
optimum care at affordable cost. Words, at least the words came into being and very
often words are the beginning of action.
Who are all the stakeholders? The States are the major stakeholders because health is a
state subject. The Centre depends upon effective state infrastructure for implementation
of the Centrally Sponsored Schemes and therefore is also an important stakeholder in
this. Health care institutions are also involved because they can function much better if
there is a defined norm. Healthcare providers, as they will get the essential requirements
7
to provide care are also stakeholders. And the people themselves have stakes, as they
need access to good quality health care at an affordable cost. So in a situation where
everybody has a stake, we need to propagate this whenever temporary difficulties are
encountered in the implementation of health systems reforms.
The health system reforms broadly fall into three categories: Structural and functional
aimed at improving efficiency, Financial aimed at improving the resources available and
governance related aimed at improving transparency. We envisage that the public sector
would play the lead role in health systems reform.
The structural reforms are essentially re- organizing and restructuring of existing health
care infrastructure including the infrastructure for delivering Indian System of Medicine
& Homeopathy (ISM&H) services at primary, secondary and tertiary care levels. They
should have the responsibility of serving the population residing in a well defined area
and have appropriate referral linkages with each other. The second major thought in this
is, mainstreaming of the ISM&H manpower and infrastructure, especially at primary and
secondary care level because they have a major role to play not only in improving access
to health care but also in counseling and life style modification, which are going to be
critical if we have to combat non-communicable diseases in this country.
Regarding human resource development, we have numbers there is no doubt about it, but
we have some worry not about the skills but about the attitudes and that is partly because
they are also getting tom between two streams. Do we go for super-specialty and high
end of technology or do we provide primary health care and when they are tom, their
attitudes obviously are going to be somewhat ambivalent for both. We urgently require
skill up-gradation and knowledge up-gradation through Continuing Medical Education
(CME) programme, so that the existing manpower can take care of emerging health
problems.
The functional reforms are horizontal integration of current vertical programmes. This is
one of the thorniest issues. All of us know that when there is a line function, it functions
well. It is good for me, I get a good response but line functions are terribly expensive and
after a time they also will go through a fatigue phenomenon. Ultimately you have to have
an integrated infrastructure delivering all health care. There is only healthy population or
people who are ill. People needing services, don’t come saying, T have tuberculosis’, and
therefore that integration is terribly important. Going along with it, there has to be district
based planning, implementation, monitoring, and Information, Education and
Communication (IEC). This is very difficult and we are taking stumbling steps in this.
Building up efficient and effective logistic system for supply of drugs, vaccines and
consumables based on the need and utilization is critical as it will cut health care cost by
reducing massive wastage that does occur at all places.
The reporting systems today are in disarray. There are multiple reporting systems, for e.g.
one for tuberculosis, one for family welfare. People fill many registers. Unless we get the
system to report reliably, accurately and tell people that it is worth it, it is going to be a
time consuming exercise to keep on motivating, evaluating and telling people that they
8
did not report well. It is a very disheartening situation for people in the field and
therefore, we need to get this system going in a much more integrated and authentic
fashion. An initiative of building up a system of disease surveillance and response at
district level was taken in the Ninth Plan. Some hundred districts were picked up and
some systems were built up. They are functioning though not very optimally. But it is a
difficult task. We have to however, slowly continue doing this.
Last, but not the least is governance related reforms. We have to introduce a range of
comprehensive regulations prescribing minimum requirements of qualified staff,
conditions for carrying out specialized interventions and a set of established procedures
for quality assurance. A beginning has been made in some. Typical example is what we
did for blood banks as a part of the AIDS Control Programme. We re-organized the
system, made it subservient to a few norms and the results are today for all to see. It may
not have served the AIDS Control Programme but it did serve a very vital function of
making safe blood available in this country and therefore, one need not look immediately
for benefits for a vertical programme, one needs to look at it, in slightly broader terms.
The major thing that we need in this country now is the standard protocols for care for
various illnesses at primary, secondary and tertiary care, the impetus for this should come
from medical colleges, professional associations. The testing ground should be public
sector hospitals at primary, secondary and tertiary care. They should come out openly
with what works and what does not. And based on that we should evolve these norms and
make them available to all. Along with that, once the standard protocol is worked out, we
should embark on working out the cost of diagnostics and therapeutic procedures for
major/ minor ailments in different levels of care and setting cost of care norms.
Very often it is stated that quality of care will escalate the cost enormously. This is a very
untrue statement. And second is the question of how to assess quality. It is a subjective
belief and you can not really document it. That is a very wrong notion too. Quality of
care can be assessed, once a norm exists, through quantifiable determinants and
ingredients of quality, which include access, infrastructure, manpower, processes for
diagnosis and treatment, safety and timeliness, a cost of care at each level, outcomes in
terms of case fatality and disability. Each one of these are numbers from which we can
draw absolutely dependable conclusions. And I think we are mature enough on this
extremely difficult exercise and if we do it right, we will set the tone for the entire
developing countries health care system. It is worthwhile doing it.
What will the quality control in India do? If we are to sweat it out so much, we should tell
the people what are the benefits. Everyone there has a rampant suspicion of overuse,
underuse, abuse, misuse of facilities, diagnostics and overcharging. Health profession,
which was once upon a time respected enormously, is losing out on this count. Quality
control system will help re-establish the same. It will of course improve effectiveness and
efficiency, help to make positive outcomes more likely, it will help us utilize the
available resources effectively and responsibly. We have to live in a globalised world, if
your systems are equivalent of International Standards Organization (ISO) certification, it
wi 1 open the floodgates of tourism, health tourism. It will cross subsidize, institutions
will survive and do well. Instead of exporting medical professionals, there is nothing
9
wrong in having health institutions, which provide good quality care at an affordable cost
in an ambience, which is familiar to people in neighbouring countries. And in that we can
do similar things as Information Technology is doing, perhaps in a more sustained
fashion for the next 30-40 years. At the primary health care level, we should increasingly
use the Panchayati Raj Institutions (PRIs) in bringing out local accountability, planning
and monitoring of ongoing programmes and also providing better access to information
on what types of service are available where and at what cost.
Financial reforms are the last and we have just started. First and foremost, thanks to the
number of people who did support it through various times. The Tenth Plan reiterated the
continued commitment to provide essential primary health care, emergency life saving
services, services under the National Disease Control Programmes and the National
Family Welfare Programme totally free of cost to individuals based on their needs and
not on ability to pay. In fact, National Disease Control Programmes and Family Welfare
services are accessible to all of us, in the highest income group, free of cost; because
there can be a gender bias, there can be problems and therefore, those services are
protected for public health cost. And that cost has been protected by people, many of
whom are sitting around this table. Further, there is a need to evolve, test and implement
suitable strategies for levying user charges for health care services from people above
poverty line, while providing free perhaps subsidized service to people below poverty
line; utilize the collected funds locally to improve quality of care. Many health
administrators, have really worked months to get these things passed through their State
legislatures because otherwise whatever user charges that are collected in any
government institution reverts back to the State’s consolidated fund and if that is done,
the incentive for them to generate adequate user charges gets killed and therefore, many
of the States now have legislations which enables these institutions to retain their funds.
Finally, evolve and implement a mechanism to ensure sustainability of ongoing
government funded health and family welfare programmes even after the currently
substantial external assistance tapers off. These were some initiatives proposed in the
Tenth Plan.
I would like to end by saying that as seen in our recent annual review, both within the
Centre and the States; there is not a single State which has not implemented reforms.
Every single centrally sponsored programme has implemented some reform. The problem
currently that we face and why we are not seeing the immense benefit that would accrue
is reforms implementation is fragmented. No body has carried out one set of reforms
fully so that dt least you can say that system is functioning well. And no state has carried
out across the board horizontal reforms. But every struggle that has been undergone by
either the Centre or the State has paid some dividends, and there is no need to get
disheartened, the initial steps are usually the hardest. Having embarked on it, persist. We
will hold hands and there is nothing but improvement ahead, please persist.
Thank you Very much.
10
Shri P. Hota
Friends, after Dr. Ramachandran’s very detailed and comprehensive coverage of the
subject of health sector reforms; I really do not feel the urge to take up your time in
stating the obvious. I would like to supplement a few points which I think could be added
to her presentation or maybe she is a seasoned practitioner, so looks at ‘do-ables’ and
leaves aside ‘un-doables’. I will try to flag a few un-doables but which must be done. We
seem to talk of reforms that somebody else would reform. That the district level, primary
health care level, private sector, even non-governmental organisations (NGOs) we have
tried to streamline, they must reform. We have seldom subjected the main health policy
formulators to any scrutiny. So talk of reform must start with looking at State Health
Department, even Family Welfare Departments. Health is a generic term for me, doesn’t
mean only the Health Department. Family Welfare and Indian System of Medicine &
Homeopathy, Directorates are all included. Similarly, the Central Governments, their
various departments and institutions must also subject themselves to scrutiny. That
process, I do not see anywhere and if you permit me to say, the international and bilateral
agencies involved in India must also subject themselves to scrutiny. I am a new entrant to
this sector, though I was a Health Secretary earlier and did interact at the Central level.
The number of people trying to reform you is immense, you hardly have any time to
really work out a programme for reforms and you have this perception that the
multilateral and bilateral agencies are to start the ball rolling by having a common
agenda. There must be convergence in their programme. You could be having a situation
where the World Health Organization (WHO) would be carrying on a workshop on
reforms and somebody else is carrying on a workshop on reforms and it does not go into
operational issues. We do not share work in a rational manner. We talk of rational drug
use; we should also talk of rational use of our management’s attention. The Central
government as I said, must also subject itself to scrutiny. Budget is not available in some
sense, but budget which is available is not properly spent. Some money is surrendered
each year, the disbursements are jerky, and the two way flow of funds and accounts do
not happen. Finance as a base of Management Information System (MIS) does not
happen. These are some of the major concerns. Our traditional issues of reforms are
already there. What Jyotiji said that ten years back such a meeting should have taken
place. These sorts of meetings did take place in various State Headquarters. There are
quite a few initiatives in State and district headquarters. These user charges, are now no
more a buzz word, they are practical words in many States. I also would submit that Dr.
Ramachandran reflected on the imbalance of personnel in this sector. Whether we need
reform of that? We initially started with health personnel, and then we have gone to the
stage of health managers. Earlier when I was Health Secretary, they were seen at the
Central level. These health managers are now seen, percolating down to the State level
but they are yet to percolate down to the district headquarter level, in at least what we call
the Empowered Action Group (EAG) States.
The health managers apart, there are some efficiency issues, which cannot be attended
through the personnel, that are engaged in this sector. But that is a generic problem in the
whole Indian administration. We have finance personnel everywhere who are not really
finance persons. They do not have the professional financial qualifications but they do
11
dominate the Indian financial administration. The health sector would benefit with the
introduction of Chartered Accountants, Cost Accountants and such people at district
level. The traditional financial personnel, who are at the State level or below at district
level, are accounts clerks who have come up through the system and who are hard boiled
ones and people like Shri Goel can make some attempt at a difference. We are engaging
and taking help of some multilateral agency to look at these issues very deeply. I would
invite attention of my colleagues from the States that this is a key factor. If funds do not
flow, accounts do not come back, no buzz word of reform will carry the system
anywhere. I see that programme related expenditure; hardly 20- 40 percent expenditure
takes place. There are a lot of failures in those specific programme related expenditures.
Then some States have carried out reforms in personnel policy. If they have had a good
effect, this should be codified and should be circulated and the Central Government
should also take note of it. And as it was said, an integrated package of reforms must start
with an emphasis on personnel. Karnataka apparently has attempted some reforms. It
would be worthwhile to listen to them, because issues of tenure, issues of compulsory
rural health service are important issues for my sector, as also for the primary health care
sector. There are statisticians galore, in this sector. But they are again in Central
Government; to some extent they are present in State headquarters. There is also a need
to look at the reforms in this area because every time you need to launch a programme,
you start with a new survey. Can we reform the process and give them a due identity,
empowerment, recognition so that statistics is generated on a continuous basis and goes
away from the survey mode which is highly expensive, dubious, time consuming. Then I
have this perception that Centre says, States should own programmes. States say that
district level should develop its own programmes. Up to the district level, the capacity
building is slightly visible. It is time to strengthen that, because ultimately we will have
to go to the Panchayat system. But in many States we are hesitant to go to that level,
because Panchayats are still seen as immature, non-functional, and non-transparent. But
how do you implement a vast health care programme, the public health content of it, if
the local self government institutions do not participate. So any agenda for reform must
address resources and attention to involving the Panchayati Raj Institutions (PRIs).
Dr. Ramachandran has more effectively dwelt upon other points, so I will not take time
of this august gathering. I have come here to learn. I would be watching out for the
documents that this workshop generates.
12
Dh S. J. Habayeb
Secretary Hota, Dr Rao, Dr. Agarwal, Dr. Ramachandran, Ladies and Gentlemen. I am
pleased to be here and I am pleased that the World Health Organisation (WHO) is
working with you on this important topic. The goals of health sector reform in a formal
sense would be the achievement of efficiency, improving quality, preserving and
promoting equity and generating new resources for health care.
Health system reforms falls in three broad categories, structural and functional, aimed at
improving efficiency, financial aimed at improving the resources available and
governance related reforms aimed at improving transparency and accountability. Health
sector reforms have been the subject of debate over a long time in many political circles.
In a nutshell, the success of reforms depends on how the process is applied and by whom,
and not only on the contents within that reform. Unfortunately, the reform frequently
tends to ignore issues relating to the process of reforms, its feasibility, implementation
and the political realities. Mr. Secretary, like you I am only going to give the bullets. We
are running out of time. The WHO has been supporting countries in health sector reform
processes. In the South East Asian Region (SEAR), in 1997 at meeting of the Ministers,
there was a declaration highlighting the challenges in the region and the first
recommendation was initiating health sector reforms to reduce the inequities in health. As
you know the region suffers from very massive inequities and creating conditions to
promote health and self reliance. This was followed by the Regional Committee which
underlined the Health Ministers Declaration, and also called for more consultation,
documentation and dissemination. As you rightly said, the language of health reforms has
changed over the years. The first generation of reforms was overwhelmingly supply
driven and focus was within the sector only. Historically, this was less successful and
worldwide we notice that success came when there was more global move towards
reforms and not only mono-sectoral effort within the health sector alone. The second
generation of reforms shifted more to the demand side and broadened to poverty
alleviation and to a broader spectrum, including more partnerships with various
stakeholders. I don’t know where we are Mr. Secretary; I think we are in between them.
In India, since the early 1990s, considerable work has been done in health sector reforms,
which involved government and other agencies. It is necessary to review, to evaluate the
impact and outcome of these efforts, as many colleagues have rightly said. The review
would aid developing future strategies and fixture options that the government and the
State governments may consider. We need viable and feasible medium term options for
enhancing service coverage for poor and vulnerable groups, while promoting efficiency
and equality. The Ministry of Health & Family Welfare and the Indian System of
Medicine and Homeopathy would play a vital role in the documentation of reforms and
provide a platform for learning from each other’s experiences. Success in reform
obviously depends on State governments, as health is largely a state subject.
Unfortunately, many reforms were propelled within a vacuum and with decentralization;
there was a vacuum at the periphery. Reforms should be linked with capacity building at
the periphery, e.g. the panchayats to be able to cope with such reforms.
13
At the end again, I would like to stress the need to document the experiences and best
practices, which are adapted to social local conditions, and not a blueprint imported from
somewhere or from an agency. We shall try to promote debates and consensus to the
extent possible and we need to jointly monitor and review health systems developments
and research to provide valid and scientific evidence for strengthening processes and
mechanisms for health sector reform. The related analysis if performed with adequate
scientific rigour would be useful in suggesting the preferred options under sector reforms
that the governments may consider.
We at the WHO, along with the other multilateral and bilateral agencies and sister
agencies are keen to work closely with you and with stakeholders in India in your efforts.
I take this opportunity to congratulate the officers of the Bureau of Planning for
undertaking this initiative and wish them all success and on behalf of the WHO, I would
like to assure you of our total and continued support.
Thank you very much
14
Dr. S.P. Agarwal
Shri Hota, Secretary Family Welfare, Shri Javid Chowdhury former Secretary Health,
distinguished participants, ladies & gentlemen. Fortunately all the things that the Director
General Health Services still in government service is supposed to say, the good things
which I too had written up, have already been stated. So I would then like to use this
opportunity to raise a few issues. The health sector reforms basically refer to
improvements in the health systems and the improvements in the health systems in turn
refers to good health. Unlike the common perception, good health has very little to do
with the Ministries of Health. I will tell you why. I am a practicing surgeon for about
three decades now. Good health as 1 have leamt, depends on environment, genetics,
social index that would mean your nutrition, your level of education, lifestyle - i.e. the
type of food intake, type of exercise and this lifestyle depends a lot on the physical body,
the emotional and mental being, intellectual level and so on. So, if we take good lifestyle,
good environment, good social index, then 90 percent of the diseases will not affect you.
So in fact, Ministries of Health, who in reality are more like Ministries looking after
diseases, in actuality, should be Ministries of Health Promotion and Disease Prevention
with some departments of disease control. So, if that is the concept of health, then for that
10 percent we need to have the advice of professionals and health reformers that Shri
Hota referred to.
Some of us tend to believe that these reforms are dependent on a number of factors,
which will vary from one place to another, one country to another, one state to another. It
depends on the beliefs of the people, it depends on the local governance, it depends on a
number of other factors which all of you know.
Let me mention a few points, which were said here. One is of course the greater
autonomy to the health institutions. Well, we need to learn lessons, as to what will sell.
We have various examples, which I would like to share. The Delhi State gave some
concessions to private hospitals but this did not work. We have another very major non
profit hospital where the management is in the hands of very eminent doctors, with the
Trustees playing a very little role. The situation works in that case as it is not merely
profit driven which is normally the case in the private sector.
Another very familiar term in the health sector reforms is ‘outsourcing’. Well, it is good
to have the laundry, kitchen and other things outsourced. But at the same time we are
facing problems. For example, recently you might have heard that there was a robbery,
bank robbery or something in the World Trade Centre, a couple of days ago, where
security, etc was just ceremonial. These people when you outsource, they are put on duty,
made to sign somewhere else but are paid very little. So you need to have outsourcing
with strict regulatory mechanism. This area really needs to be looked at again.
The problem that we talk about is mainstreaming. Mainstreaming of what? We are
talking about mainstreaming of practitioners from ISM&H. Are we talking about
integration of these services? The issue is that unless we really want to demolish
15
Ayurveda from this country, we need to look at availability of facilities under the same
roof. People have a choice. We know for certain, I am not holding a brief for modem
medicine, but the fact is that we know that 80-90percent of these doctors use modem
system of medicine, whether they are ‘A’, ‘B’ or ‘C’ drugs. Facilities of different systems
of medicine should be available under the same roof with greater interaction between
experts of different types. A small experiment has been started in the Central government
hospitals, we have an Ayurveda clinic in Ram Manohar Lohia hospital and we have a
Homeopathy and Ayurveda clinic in Safdaijung Hospital. That is the type of integration
which is required; otherwise we will land up with a system which may not be right for us.
Who is doing the health sector reforms in this country? I will tell you, let us not feel shy
and say, it is the judiciary that is doing the health sector reforms for us. They said that the
safety belts should be compulsory for the cars and next day you see it all over. They only
said that helmets should be compulsory. Head injury is a public health problem today.
We as neurologists have been crying hoarse over years, that if you don’t have helmet and
you drive, you may get a serious brain injury. They said that clean environment is
important; if you have this type of fuel then there would be pollution. The environment in
this city as everyone knows has changed. I think they continue in this vein. These are
some of the major reforms in the health sector, to my mind.
Now the question was of greater investments in health. Yes, sure. The main architect of
the National Health Policy, Shn Javid Chowdhury is here. I had the fortune of assisting
him. Yes, you have to increase the public health investment from 1 percent to 2 percent
of the Gross Domestic Product, but what we learnt from Shn Chowdhury simultaneously
was that you have to have the greater capacity to utilize those funds and prior to his
joining, if you see the record it is not very happy. Different types of funds were getting
lapsed year after year, not only here but at many places.
Then, the issue is that of utilization of existing infrastructure. Dr. Prema Ramachandran
showed us a huge infrastructure that has come up, especially in the government sector.
Now the issue is that our monitoring mechanism needs to be put in place. You might
have a working Magnetic Resonance Imaging (MRI) system which probably does 2-3
scans a day, while the one across the road with the private sector, might do 40-50. So the
question is of proper utilization of the existing infrastructure by way of public private
partnership. One could evolve a mechanism wherein expensive equipment like MRIs,
computerized tomographic scan (CT scan), catheterisation (Cath) laboratories and other
things, are provided by the private sector while the government provides the place,
electricity and other facilities for the private sector to install its equipment. The private
sector would have the responsibility to make the set up operational with a stipulation that
these services would be available to the poor patients on a priority basis.
Another very important area that was referred to was the lack of proper health care
planning and management of human resource. How many surgeons, orthopaedics,
gynaecologists are required? It is nobody’s business. If some one wants to become a
gynaecologist and he has role model, he gets into that system. So there is an urgent need
for a system to be put in place to look at this; that 5-10 years down the line, we require so
16
many surgeons, so we need to increase a few seats and we will have to decrease some
seats in some other speciality. I again quote Shri Chowdhury. We debated this intensely
during the weekend meetings that he used to hold on health policy. There is a system,
where we said that 25 percent of the new post graduate seats will be progressively
earmarked for the public health professionals and for the family physicians.
Before I close, I would like to say that these health system reforms have to be very
flexible. Small pox went away; we thought that nothing more will happen. More than 20
virulent viruses struck us; the latest was Severe Acute Respiratory Syndrome (SARS).
You know when the Surat plague took place, the country became poorer. Apart from the
shame, flights were stopped; a loss of US $ 1.4 billion took place. So, you have to have
flexibility. You can not be straight jacketed, importing a type of system, expecting that
everything will fall into place, if this is followed. It has be flexible depending upon the
situation. The latest of course was Severe Acute Respiratory Syndrome (SARS), where
effective steps were taken, although we had 30 lab positive cases and 3 definite or
probable cases, which could be controlled.
I would now close by finally saying a few words about the system of posting of doctors
in the rural areas. This is our favourite subject. Time and again, since the last five
decades, we have been saying that there should be compulsory posting of doctors.
Doctors, who do not go to the rural areas, should be given compulsory posting and they
should not be allowed to do their post-graduation unless they do this. I think this colonial
mindset has to go. If you have to really serve the people, let me be very candid about it,
because the primary health care business does not involve any foreign travel, is not as
glamorous as AIDS probably is, it is to do with poor man so nobody is really bothered
and unless this base becomes strong, unless our primary health structure becomes strong,
nothing will happen. I have a small, brief suggestion to make. We have the practice of
young men and women getting into medical services. By the time they are 22 or 23 yrs
old, these boys and girls become doctors. We train them that once there is a headache, do
a CT scan or MRI, whether it is due to sinusitis, brain tumour or tension headache. These
doctors, even if one is able to force them to go to a primary health centre, what will
happen? He or she is in competition with a village quack who is a punditji or some school
teacher, who is working there for 30-40 years, who works on superstitions and beliefs. I
know of a young doctor who was trying to resuscitate a person by cardiac massage that
we teach them and the villagers gave him a beating, because they felt that the young
doctor had killed the patient or broken his ribs by pressing his chest too hard. The issue is
that according to the villages, this young doctor was not competent to treat the patients
there. The doctor is trained to work in a group, under guidance and then it takes the best
out of him. We feel there is a model. Why is it that doctors do not go to rural areas? It is
because there are no places to stay, no security, no electricity, no water, there is no
education for their children, there is nothing and to say that the ISM doctors will go there,
please understand that it is a myth. We had a system 20- 30 years ago, of licentiate
doctors, they had been trained for 2-3 years. None of them stayed, all of them at the first
opportunity got into M.B.B.S and then they completed their MS or MD, who so ever
could get, they migrated to cities. That is the natural tendency. Instead of pushing it under
the carpet, we must accept this reality. Our people need to make the primary health
17
centres vibrant by people who can really manage. There are middle level doctors and all
of them belong to some villages or towns. We all have home town advantages. We say
that we belong to that village or to that town. Depending on that, it should be possible to
post them for tenure of 1-2 years, where their children and families will continue to stay
in cities and towns and get education. This man or lady goes to that village in the
primary health centre on a tenure posting, he knows that he is not going to be dumped
there for ever. He has over 15 years of some training. He can treat patients with his
experience, he can relate to those people. People consider him as a son of soil. He speaks
the same language; he is accepted there and that gives him some autonomy to function.
Chances are that some of them would actually settle there. Nobody wants to stay in small
flats in towns, in the polluted areas that we live. So if we have a plan to post middle level
doctors to the places to which they belong in a rotational manner, nothing compulsory,
say during the age of 40 - 45 years, he is given the flexibility to choose a year when he
would be willing to go and work in the village at the primary health centres, chances are
that many of them would settle there, probably they would be able to do good service and
all the national health programmes that we have will actually function. I must say that I
have failed to sell this idea to many of the people who matter but I thought that it is a
very great opportunity in such an august gathering, I have again tried to put this forward.
I know that this country is of continental proportion, the type of terrain we have, the type
of people we have, and what succeeds in one country will not succeed here, what
succeeds in one state may not succeed elsewhere, what succeeds in Karnataka may not
succeed in Bihar, so it is an extremely important workshop where the States tell their
experience and we tend to emulate and learn from them and in that regard I would
congratulate the Bureau of Planning and thank them, especially Smt. Sadhwani who
organized this workshop and gave me this opportunity to be here with you this morning.
Thank you for your attention.
18
TECHNICAL SESSION
Technical Sessions
Dr. Rama Bara
Dr. Baru provided an overview of health sector reforms (HSR) and spoke of national and
international experiences in this area. She located HSR in the larger political and
economic context, examined the elements included in HSR, the role of donor funding and
national as well as international experiences with HSR.
Dr Baru began by emphasizing the need to relate the debate on HSR with the world
recession on the late 1970s and early 1980s, which mainly occurred in the developed
world and where concerns had been raised about escalating costs of care and not having
enough to spend on public sector. The supporting ideology was a lesser role for the
government and an increased role for the market. This was the context in which health
sector reforms emerged. A formulation which is commonly used is that public
provisioning was seen as inefficient as compared to markets, markets were characterized
to be more efficient in terms of costs, and also in terms of being responsive to patients
needs. Since the emphasis was to reduce state involvement or to rationalize costs, number
of methodologies were developed, both for assessing and prioritizing investments in
health. Cost effectiveness was the basic underlying objective. The strategies employed
included amongst others introduction of user charges in public facilities, provision of
incentives and subsidies to the private sector.
Another key issue raised by Dr. Baru pertained to defining ‘health sector reforms.’ She
posed the question, ‘what is a commonly accepted definition of HSR?’ and what are its
varied elements? She proposed that an accepted definition of HSR includes improving the
civil service, decentralization of power and resources, improving function of health
ministries, broadening health financing (including finding alternate sources of financing)
and increasing role of private sector in the financing of provisioning of health care. The
elements included in HSR, are privatization of health services specially at secondary and
tertiary levels of care, introduction of cost recovery mechanisms that were seen to
enhance cost effectiveness and also improve quality of services, including inter-alia
introduction of user fees; contracting out of ancillary services in public sector,
implementation of “essential services “for specified target groups at the primary level and
decentralization of services, both financial and administrative.
Drawing the link to developing countries, Dr. Baru felt that it is pertinent to examine the
relationship between HSR, its global understanding and how HSR was actually
opertionalized in developing countries. The larger context of resource constraints in
developing countries (as was also the case with developed countries) also needed to be
kept in mind. Health sector reform was clearly driven by an ideological position which
placed better faith in markets than the State and this was borne by differential experiences
of effectiveness of public sector health provisioning across the world. Debates occurred
m Great Britain, China and a range of developed and developing countries. The important
things that need to be factored in were elements of HSR which were globalized by
bilateral and multilateral agencies. The HSR process received an impetus by the bilateral
19
and multilateral agencies (though they were not the only ones who pushed health sector
reforms). But these ideas had influenced health system provision already.
Dr Baru stated that one of the motivations for donor involvement in health sector, (as is
also stated in some of the writings of the World Bank) was to cushion the impact of
globalization. She said that the importance of the need to invest in health comes out in
terms of the inequities that arose especially from the experiences of the African and Latin
American countries where blanket privatization led to enormous inequities and collapse
of the public systems. The desire to rebuild them at a later point became a difficult task as
there was no public money. So through loan financing from the Bank there was an effort
to rebuild or save through safety nets some sort of a public system once again. And it was
also seen clearly as a way of rationalizing costs in the health sector.
Drawing from international experiences, she stated that across the world till the 1980s,
the bilateral agencies had a fairly dominant position as far as funding was concerned. A
shift occurred in the 1990s. Clearly, the World Bank had a role in sector wide
programmes like nutrition, population, but they emerged as the single largest funding
agency and started setting the trends and priorities in terms of policy interventions
globally while various other bilateral agencies dove-tailed to the World Bank
programmes. Across the world, the loans to the health sector were tied with
conditionalities in terms of defining programme content, choice of technology,
programme priorities etc. This has been documented across the world in the Bank’s own
literature as well as other work undertaken.
Coming to the Indian context, Dr. Baru said that what is significant about the health
sector reform agenda is that there is funding from multilateral and bilateral for specific
projects. She spoke of her past work of trying to obtain perception of donors and main
actors in the Ministry about health sector reforms in India. A common response to the
question, what is health sector reforms, was that it is ‘a grouping of projects which
includes disease control, preventive and child health, primary health care and
restructuring of secondary and tertiary health care.’
In terms of assessing the impact of health sector reforms, experience largely from
African, Asian and some Latin American countries through various studies has shown
that the option of user charges has reduced access, especially for the poor and the middle
classes. It is being seen that indebtedness due to especially high costs of medical care is
pushing families from the ‘middle class’ to lower level. This is especially the case for
countries of South Africa, Brazil and Chile. This set of evidence has set the World Bank
itself thinking, with the Bank documents of the 1980s and the 1990s indicating a
perceptible shift and recognition for putting equity or at least reduced inequity at the
centre of the reform agenda. The other issues brought up by Dr Baru pertained to
privatization and corporatization of health services which has led to increased costs as
depicted in India as well as the United States. The issue of regulation is critical in this
context and she felt this should be an important part of the health sector reform debate. In
terms of health sector reforms in India, she drew attention to the fact that few elements of
HSR predate the Structural Adjustment Programme and the World Bank. Privatization in
20
India has occurred since the mid 1970s but at an accelerated pace in the 1980s and 1990s.
In 1991, India opted for the Structural Adjustment Programme and the loans from the
World Bank with support from the bilateral agencies. These loans were sought to deal
with the fiscal crisis in the health sector, especially at the state level. These loans were
given to specific projects that included disease control programmes, Reproductive and
Child Health programmes, primary level care and the state health systems projects that
dealt with Restructuring of the public sector. Each of the projects had a specific
conditibnality to the loans. To illustrate, in case of the Disease Control Programme,
priority Was accorded to certain diseases like tuberculosis, malaria and HIV/AIDS.
Debate also occurred over the kind of technology that should be used, in terms of the
drug£, regimens. Negotiation did occur amongst different players and conditionalities
played a part in influencing policy. Similarly, a review of the health systems projects
outlines a clear break up of budgets in terms of civil works, drugs, purchase of equipment
and also use of coiitracting out of services and user fees.
Pertaining to information availability for HSR in the Indian context, there is paucity of
information; some studies are available from the early reforming state of Andhra Pradesh
on completion of the first referral health systems project. A review of the secondary
health system projects show that a large percentage was spent on civil works, equipment
and drugs. She illustrated her point by stating the case of Andhra Pradesh. In Andhra
Pradesh, investments were made in the health sector, infrastructure from the level of
community health centres (CHCs) to the district level hospitals was well developed but
there is worry in some of the studies conducted after the initiation of reforms. The
reforms were initiated with the view that it would attract patients back to the public
sector. Unfortunately, the Andhra Pradesh experience has shown that the paying sections,
viz. the middle classes did not move back to the public sector in significant numbers. The
National Sample Survey (NSS) rounds in the mid 1980s showed that the middle class in
Andhra Pradesh had already moved to the private sector as far as consumer care was
concerned, with Andhra Pradesh being a State with high private sector growth. There was
worry in the Andhra Pradesh government as to how they would financially sustain these
reforms, how they would obtain the finances to proceed with what had been created. A
small study was conducted by the Administrative Staff College of India (ASCI) using
data from the community health centres and Andhra Pradesh Health Systems data. The
study showed that this worrying trend had already set in.
In relation to the issue of user fees, Dr. Baru stated that even the international experience
of user fees has not been a very happy one. The proportion recovered from user fees to
the total revenue in the health sector was very small. The exercise in an African country
undertaken by Creese shows that recovery rate ranges from 0.2 to 12.5 at the maximum.
She stated that the World Bank itself has gone easy on user fees. While they were vocal
about it, user fees as a concept has been a non-starter in terms of the extent to which it
would be able to generate a great deal of revenue. Dr. Baru pointed out that the concept
of user fees has a political dimension in the Indian context. Citing an example of Andhra
Pradesh, she said that when the user fees were introduced there was tremendous protest,
and the fees were withdrawn, but now there are plans for its re-introduction. She gave
instances of how the Uttar Pradesh government had passed a law for user fees, which has
21
been reversed by the new Chief Minister. While user fees are seen to be a way forward,
the political context determines how it works and the state experiences have been varied
in this area.
To summarize, she said that essentially there is some data available from international
experiences. In the Indian context, we have some notions of what HSR are, some
elements of HSR have been incorporated by States but one does not know what has
happened, and what the experiences have been what has been the impact of such reforms.
She stressed the importance of being able to document and track reforms, because only
then impacts can be studied. This is crucial when States begin initiating reforms. She said
that the government is still committed to some notions of equity and universality. If one
wants to adhere to that, it is also necessary to define impacts. And we need to as part of
this workshop deliberate as to where and how we are going to do this. There is a need to
document and share the process and experience of HSR across states and felt that the
present workshop is an important contribution to this area.
Thank you.
22
State Presentations
1. Punjab
Dr. Anjali Bhawra, shared health sector reform initiatives undertaken in the state of
Punjab. In her presentation, Dr. Bhawra focused on why a need was felt for health sector
reforms and how it is linked to the aid received from the World Bank. She also focused
on programmes put in place to improve the health delivery system, but may not be known
as health sector reforms.
Punjab started implementing health sector strengthening programmes with the support of
the World Bank since 1995-96. 154 secondary level organizations were selected in the
state. The assistance received was to the tune of Rs. 470 crore and included a civil
component, equipment component and drug packaging. Health sector reform was
engaged with a view to improve the quality of health care delivery system. Given the
limitations of the costs of health care delivery, increasing health expenditure especially
for below poverty line families is a long sought goal. Resource allocation dilemma
always exist and the perception of performance in the health system gets compounded
due to lack of patient satisfaction, heterogeneity of patients seeking care from the public
health system and intangible outputs. In the state of Punjab, the process of reform was
initiated with re-evaluation of the health needs of the community, assessment of the
deployable resources in health sector, and analysis and reprioritization of the needs and
resources.
Initiatives taken by the Government of Punjab:
After receiving funds under the Secondary Health system project, Punjab began
implementing user charges, linking additional resources to improve health care delivery,
retaining and utilizing user charges at the point of collection, vesting higher financial
powers to bring more autonomy to CSO level. Other initiatives included, democratic
decentralization (i.e. handing over of primary care systems to Panchayati Raj Institutions
(PRIs) and outsourcing of services in secondary hospitals. Some of the schemes which
are in pipeline include medical insurance scheme, public - private mix, revamping of
primary health care services, health care delivery through better mobility and emphasis
on maintenance of assets & optimum utilization. Dr. Bhawra then detailed out the
experiences in select areas. These are:
A. Implementation of user charges
Initially user charges were implemented category wise. Subsequently, slabs were
removed and user charges are now being imposed uniformly. 2.5 percent of charges
collected are ear marked to be spent at the institution level for poor categories. This is
being done at the discretion of the SMO. Dr. Bhawra opined that the current user charges
need to be revised but these she felt were harsh decisions in the political context. This
proposal is under consideration. The collection procedures have been made more
rigorous. Also, these have been computerized in 40 hospitals and centralized. In terms of
rationalization of user charges, limits have been laid down on how that money can be
spent - e.g. regular maintenance, outsourcing of the activity and on drugs. Institutional
23
level officers have been authorized for purchase of drugs. The indexing of user charges
has been done in order to cover operational expenses excluding manpower cost and
capital cost. The major policy change has been allowing for retention of user charges at
the institutional level and setting out priorities on its utilization. In order to bring about
more autonomy and accountability various activities are being tried out. This includes,
delegation of higher financial powers to doctors at various levels, introduction of systems
to monitor breakdown of diagnostic equipment, inculcating a sense of belongingness and
ensuring management of emergencies.
B.
Health Insurance
The Punjab government is in the process of finalizing a health insurance scheme. The
terms of reference have been approved by the World Bank, who has indicated an interest
in funding the same. This scheme proposes to address the unmet need of government
employees, pensioners, and people below poverty line.
C.
Democratic Decentralization
In the area of democratic decentralization, i.e. decentralization of primary care
institutions to PRIs, the deadline for implementation is October 2nd, 2003. The immediate
powers which would be transferred are the supervisory powers. The government has
prepared a schedule of the financial powers and the administrative powers to be
transferred to PRIs along with the time frame. The schedule has been communicated to
the Directorate of Rural Development and Panchayats (DRDP) for confirmation. All
services would be delegated to PRIs in a phased manner.
D.
Outsourcing of services
The Punjab government has begun outsourcing of services in secondary level hospitals.
The services relating to security, dental services, sanitation and ambulance services have
already been contracted out. It is proposed that diagnostic services, medical waste
disposable services, cash collection services, computerization services and maintenance
services would also be gradually outsourced.
E.
Public private mix
Pertaining to the area of public private mix, the government has identified one hospital
and is in the process of leasing out operation and maintenance (O&M) to the private
sector. Certain conditions would be laid down, which would ensure that poor patients are
taken care of. This proposal is presently in the pipeline.
F.
Others
Since, clinical level services at the secondary level have been strengthened, the state
would like to fill the gaps in the health care system at primary health care as well as
strengthen the linkages between primary and secondary system, so as to ensure that
clinical services are available to maximum number of people. Hence, there is a proposal
for revamping of primary health care services. The state would be trying out schemes like
introduction of mobile health clinics, benchmarking in hospitals, etc. Attempts at
ensuring a waste disposal system are underway, training and re-training in this area is
being done. Other measures adopted include reviewing the performance of all hospitals
24
on a monthly basis. Nodal officers (Deputy Medical Commissioners) have been
appointed in every district. Through the Health Management Information System (HMIS)
system, reports relating to number of surgeries performed, bed occupancy rates, etc are
obtained and hospitals are graded and hospital performance is commented upon based on
the set norms. Training is seen as an important component, especially for para-medics.
To conclude, Dr. Bhawra emphasized that these efforts are being made to improve the
health delivery system in order to ensure that the facilities are accessible to all, especially
the poor in the state of Punjab.
25
2. Rajasthan
Rajasthan Health Sector Reform: A Perspective, was presented by Dr. B Sekhar wherein
he focused on three main areas. He began by giving a brief introduction to Rajasthan,
examined the past efforts at health sector reforms and outlined the unfinished challenges
for the state.
Dr. Sekhar presented a broad profile of Rajasthan relating to various social development
parameters like population, literacy rates, health status indicators, health care
infrastructure, and distribution of human resources amongst others. He then presented a
brief analysis of public health expenditure. The diversity of Rajasthan, the decadal
growth rate and use of public sector by different sections of the population was also
presented. Thereafter, Dr. Sekhar went on to share the past efforts undertaken in the area
of health sector reforms by Rajasthan. These broadly covered the areas of financing
methods, changes in health system organization, regulation of private sector, re
organization and re-structuring of existing government health care system, reforms
related to human resources, drug policy and procurement, policy reforms, private/ non
governmental organisation / voluntary and public partnerships and equity enablers. The
details are as under.
A) Financing Methods
Medicare Relief Society (MRS) is one of the significant reforms in Rajasthan. MRS was
created in 1995 in all hospitals with 100 or more beds under the Rajasthan Societies Act.
The societies are registered at hospital level, district level and sub district level and have
now been expanded up-to community health centre (CHC) level. The first attempt at
establishing pay clinics and auto finance scheme such as user fees was made in 1980, but
these attempts were unsuccessful. The probable reasons for that include, lack of any
incentives to generate revenue, and the fact that the revenue generated was deposited in
the State Treasury. Learning from this experience, the MRS sought to compliment and
supplement the health facility thorough generation of additional revenue, to retain and
use the resources generated in the hospital through decentralized decision-making. The
MRS includes various components of health sector reforms such as decentralization as it
has capacity to decide the user fees and to determine how the user fees would be utilized.
No guidelines have been established how the user fees are to be utilized, the same would
be determined by the people and the local officials. It also provides low cost diagnostic
and treatment services, free medical services to poor and disadvantaged, obtains
donations from financial institutions, conserves resources through adopting wards and
opening of life line fluid stores and contracting out of facilities such as Sulabh complex
and the maintenance of buildings and equipment. The management structure of MRS
consists of an autonomous management committee comprising of official and non
official members at State, Regional and District levels. The Executive Committee takes
day to day decisions. The source of funds for the Society includes seed money by State
Government, transfer of operational control of diagnostic machines to the societies. The
societies are authorized to levy user charges, to retain income from auction of other
support services and to accept grants and donations and loans. The Society functions
outside the purview of the State and the Government Financial Rules (GFR) do not apply
26
and they can purchase equipment according to its own requirements. The people
exempted from payment of any charges include the families living below the poverty
line, widows, freedom fighters, destitute, citizens over 70 years and retired government
servants. The money collected is utilized for maintenance and renovation of buildings,
maintenance and repair of equipment, purchase of new equipment, improving sanitation
and cleanliness, improving other facilities for patients and attendants, computerization of
various systems, provision of free medicines for below poverty line (BPL) families Past
studies have shown that the funds are used appropriately, though some cases of
misappropriation might also have come to fore.
Dr. Sekhar then shared the experience of establishing Life Line Fluid Stores (LLPS),
which function in all hospitals with 100 or more beds. As part of this initiative, I.V
fluids, surgical items and injectable antibiotics are provided to patients at marginal profit.
These services are available 24 hours and there is no financial involvement by the
department or M.R.S. This initiative has been widely appreciated. The Society continues
to grapple with challenges pertaining to rationale use of surplus funds, how to ensure free
services to exempted categories, ensure 25 percent of surplus funds for below poverty
line (BPL) families, use of funds in same financial year, developing systems for setting
user fee, expanding the scope for levying user fee and ensuring proper systems for
perspective planning and accounting.
B, Changes in Health System Organization
The changes in health system organization include decentralization, granting autonomy
of hospitals/ CHCs / PHCs, contracting-out which in turn encompasses, appointments
being made on contract-basis, and the Information, Education and Communication (IEC)
Bureau. Dr. Sekhar briefly specified the kind of changes being undertaken in each of
these areas.
In the area of decentralization, district health societies have been formed headed by the
Pramukh of Zilla Parishad. Under this society, the various societies of the National
Programmes have been merged. There has been a relocation of Dy. CMHO offices.
Studies have shown positive impact arising out of this change. Powers have;been
delegated / devolved to the Panchayati Raj Institutions. Autonomy has been granted to
institutions like the Medicare Relief Society as discussed earlier. Contracting put has
been done in various ways. This comprises the cleaning services in hospitals,
appointment of computer operators and computerization on Built-Operate-Transfer basis.
Appointments on a contract-basis are being given to Auxiliary Nurse Midwives (ANMs),
Laboratory technicians, Staff nurses and medical officers at the district level. Changes are
also being made in the functioning of the IEC Bureau, which established in 1990.
Attempts are underway at comprehensive reorganization of fragmented efforts in IEC,
planning, monitoring of these techniques, research and experimentation and production of
material and providing technical support services.
C. Regulation of the private sector
This is another area where reforms are underway. The enactment of the Rajasthan
Clinical Establishment Regulation Bill, 2001/ 2002 is in process. This Act would soon be
27
sent to the Assembly. Dr. Sekhar, also briefly shared about the Rajasthan governments
unsuccessful initiative in formulating an Anti-Quakery Bill.
D. Re-organization and Re-structuring of the existing Govt. Health Care System
This has included initiatives like the relocation of the office of the Dy. CMHO.
E. Reforms Related to Human Resources: Reforms in this area comprise of initiating a
three month training to address the shortfall of Anesthetists. It aims at rational allocation
of resources and certification.
F. Drug Policy and Procurement reforms consist of formulation of an essential drug
list and directions for implementation.
G. Policy Reforms: In the arena of policy reforms,. the following policies have been
framed. These are Population Policy & RG Population Mission, training policy, essential
drug policy, policy to promote private sector and transfer policy amongst others. Health
Vision 2025 is being worked upon. The other policies under consideration are
formulation of a State Health Policy, Anti Quackery Bill, Clinical Establishment Act,
Regulatory Authority for Health Care and Medical Education.
H. In the realm of the Private/ NGO/ Voluntary Sector, the existing schemes are Jan
Mangal Scheme, Swasthya Mitra - village level worker based on the Madhya Pradesh
experience, encouraging private medical colleges, nursing colleges and schools.
I. Equity Enablers: The equity enablers include the BPL Medicare Card Scheme being
implemented by the MRS wherein cards have been distributed to these households and 25
percent of funds raised under the Society are used for purchase of drugs for them.
J. Others: Dr. Sekhar opined that the experience of the MRS should be studied
extensively. It has done a great deal for health sector reforms. There is a need to examine
the innovations, the gaps that require to be filled up and to examine the multiplier effect
of user fees. He also stressed the need for an enabling environment for policy. There
exists only one Secretary for Health & Medical Education. Given the scale of work, it is
suggested that there should be three Secretaries, each looking after Health, Medical
Education and Family Welfare. Several experiments were tried in this area. There is a
need to re-examine the existing administrative set up, especially in the light of the
burgeoning number of mega hospitals and lack of appropriate manpower to manage
them. He posed the question that we might want to examine whether restructuring the
departments as urban health and rural health might be more appropriate. The other issue
is of enhancing management capabilities, addressing geographical, social, gender
inequities, encouraging and regulating private sector, improving quality and protection
from impoverishment. He also emphasized the need to examine the equity element in
relation to establishment of medical colleges, the need to enhance the role of paramedics,
given the size of the private sector and the increased need to have discussions about the
private sector and it’s functioning. There is a need to ensure some mechanism for
ensuring accountability of the private sector, wherein initiatives need to come from the
28
Centre as well as the States. Dr Sekhar also posed critical questions, relating to insurance,
as to whether we had the management capacities as well as resources to implement such
schemes.
29
3. Gujarat
Shri S. K. Nanda, traced structural, functional and systemic initiatives undertaken in
Gujarat. He was of the view that reforms should be placed in the context of Alma Ata, the
objectives of which include inter-alia community participation, health promotion, equity,
appropriate technology and multi-sectoral collaboration. To this, he felt we need to add
health mapping and prevention of morbidity. Shri Nanda emphasized the need to invert
the triangle, wherein primary health care has become the tip with curative care forming
the basis. Pertaining to health sector reforms, he mentioned that small steps have been
taken in Gujarat to correct the inadequacies in the system.
A. Grouping the Community Health Centres (CHCs)
In terms of health delivery, the CHCs are emerging as a crucial first referral unit, and are
important centre of activities. Many specialists are getting spread out in the districts and
it was anticipated that many things would be done by these persons. Hence, a practical
initiative was taken by grouping the CHCs in an attempt to enhance resources. There
would be 1-2 mother CHCs, and at least 4 specialists who are available in the 50 km area
would be brought to the selected potential CHCs by rearranging their posts. He voiced
the opinion that one of the reasons that people spend more on private sector is due to
quality of care, including the waiting time, the promptness of service, the behaviour of
the service provider, the clinical outcomes and post care concerns. Issues relating to the
availability of doctor, his / her accessibility, the transport facilities, facilities inside the
hospital amongst others detract the patients from approaching public sector institutions.
Hence, it was decided that attempts would be made at regrouping of CHCs and
identification of mother CHC, a first referral unit of excellence.
B. Decentralization - Creation of Block Health Office
Shri Nanda shared that in Gujarat, gaps have been identified in terms of lack of personnel
at the Taluka / Block level. A person at this level can help in optimization of time by
attending meetings or attending to non-officials who begin delving in matters of public
health. Personnel at the block level would function as an ‘insulating rod’. S/he would
interact and intermediate with all the multi-sectoral agencies and programmes. This has
led to creation of Block Health Office, to assist District Health Organisation in planning,
implementation and review of activities related to PHCs, to facilitate supplies of
medicines, vaccines and other supplies related to implementation of relevant National
Health Programmes, to facilitate health-related data flow from the primary health centres,
to analyze, communicate and give feedback to the concerned officials thereby improving
quality of delivery of primary health care, as well as enabling effective supervision at the
Taluka level.
C. Establishment of Emergency Obstetric Care:
The third area of reforms has been the establishment of Emergency Obstetric Care (EOC)
centres in tribal and inaccessible areas, aiming to address the high maternal mortality
rates. With the use of wireless technology, communication and transport of patients to
facility in time is being achieved. The use of technology has made it possible to reach
previously unreachable areas. This project is being piloted in one taluka with training and
30
net working for early referrals. It is proposed that very high frequency voice
communication through wireless would be provided in 32 sub-centers, 8 PHCs, district
hospital and mobile vans. Upgraded ambulances having facilities for emergency critical
care and newborn care would be available at the district hospital. The staff of district
hospital and primary health centres would be trained in emergency obstetric care and
newborn care and district hospital facilities will be upgraded. Rs.50 lacs have been
sanctioned under planned activities of the state budget for this initiative.
D. Application of Geographical Information System (GIS) iu Malaria
The other model being tried out is that of application of GIS in planning of activities
related to malaria control. Mapping of all 18000 villages has been done for the last four
years for micro planning of control activities by district and sub district officials. The
village wise data for four important malaria indices has been categorized them in to four
levels. “Remote Sensing and Communication” [RESECO] a governmental organization is
working for institutional capacity building by combining the use of GIS and pictures/
images received through satellite.
E. Granting of powers to Medical Officers
Another area where reforms are being carried out, is granting powers to medical officers
to spend Rs. 10,000 - 15,000 for minor structural repair work in primary health centres or
sub-centre buildings with a limit of Rs. 25,000 per year. These powers are limited for the
grant received from donor agencies. Similarly powers for civil works are delegated to
District Reproductive and Child Health (RCH) societies up to Rs. 10 lacs for a single
item.
F.
Contracting out
Services like IEC are being contracted out. The intention is to pool together the best
information through a system of contracting. One of the players is the pharmaceutical
companies, who have their own IEC budgets. The money is pooled together on a
common basis and the agencies hired by the private sector are allocated the money
through a special sanction. Hence, attempts are being made to build partnerships to
ensure wider coverage.
G. Reorganization of the entire cadre of Para Medical Ophthalmic Assistant
(PMOA) The cadre of Para Medical Ophthalmic Assistant (PMOA) is being reorganized
according to community needs. This is being done by relocating PMOA posts in Primary
Health Centres to the community health centres to facilitate use of the primary eye care
service like refraction, treatment of primary eye care, etc.
H. Urban Health Care
‘Urban Health Care’ Project is proposed for providing primary health care to urban slum
population under public private partnership by community based health volunteers in
urban areas. Given the lack of infrastructure in urban areas, towns with less then one lakh
population would be covered under this scheme. The community based health volunteers
would be selected from local areas and they will act as link between service providers
and community. The towns either have community health centre / primary health centre/
31
post partum unit / urban family welfare centre or trust hospital, which would monitor the
activities. They will be paid monthly honorarium as per the approved scheme. This
scheme would be tried out on a pilot basis.
I- Appointment of honoraries and part-time specialists to encourage private
practitioners under "Samaydan scheme"
~
This scheme aims to ease the problem of vacancies of specialists in health and medical
services. The government of Gujarat is appointing honorary and part-time specialists. So
far, about 125 such specialists have been appointed. The government has encouraged
private practitioners to give the services in public sector under ’’Samaydan scheme". As a
part of this, govt, is actively considering the removal of age-eligibility criteria for
appointment of doctors in govt, services.
J. Extending partnership spirit with NGOs
The management of primary health centres and community health centre has been taken
by non-governmental organisations under a partnership programme. So far one primary
health centre and three community health centres have been handed over to non
governmental organizations for running the same, while nine proposals are under
consideration
K. Link Couple Scheme
The Sector Reform Cell committee has approved scheme of link couples in rural areas.
Under this scheme, 10 Couples married during last five years and having aptitude for
social work will be selected from villages where the post of Auxiliary Nurse Midwives
(ANMs) post is vacant or not staying at the Head Office. They will act as link between
service provider and community. Good couples will be rewarded in cash every quarter.
Budget is Rs. 10, 000 per primary health centre per year.
Establishment of Quality Control Circles to improve quality of health care
services by means of capacity building
Primary health care is provided through a network of community health centres or
primary health centres and sub-centres. So far the emphasis has been on quantity. To
improve coverage and patient satisfaction, quality of services requires to be improved. It
was planned to implement quality control circle in one Taluka of Rajkot district under the
European Commission supported Sector Investment Programme. The base line study has
been completed. As a part of this initiative, medical officers and primary health centre
staff of Sabarkantha and Dahod districts have been trained. This project was taken up
under the United Nations Population Fund (UNFPA) assisted integrated population and
development project with the aim of creating awareness about quality among staff
32
M. Establishment of Blood Transfusion Grid/Network
Most of the blood banks exist in the urban areas and are operated privately. It has been
felt that networking of blood banks is most urgently required to deal with the issue of
maternal deaths. Hence, first referral units would be identified in the state to establish a
network. Under this scheme, it is proposed that blood collection and storage facilities are
developed as per government guidelines at district hospitals and first referral units
(FRUs). A networking of blood banks operated by government, trust hospitals and by
private owners would be done.
N. Capacity Building
Health training is being planned through involvement of peripheral training institutes of
relevant expertise (management, administration etc) available with private/ non
governmental organization (NGO) sector. Mapping of the expertise available for training
in private and non-governmental organizational sectors and involving them in training
and in sharing of the information (e.g. IDS).It is proposed that these programmes would
be run on shared work schedule.
O. Others
The other reforms include involving community in health service delivery and provision;
arranging for sharing of information for surveillance from the private clinics. This would
include training community volunteers and National Social Service (NSS) students,
specifically girls and women groups, about primary health care, reproductive health care,
essential trauma care and essential obstetric care, amongst others.
33
4. Himachal Pradesh
Dr. R. N. Mahanta presented on health system reforms in Himachal Pradesh. He traced
the process of reforms along with their content. Dr. Mahanta shared that the genesis of
health sector reforms can be traced to a combination of factors. Besides the keenness of
the State Government to reform the Health Sector in Himachal Pradesh, two
Organizations - GTZ (German Project) and European Commission Programme through
the Government of India are supporting reforms in the health programmes and activities
in Himachal Pradesh. Dr. Mahanta spoke of reforms that have occurred in the area of
financing methods, health system organization, delivery and nianagement, role of
panchayati raj institutions (PRIs) in health, contracting out of services, promulgation of
the Himachal Pradesh Paramedical Council Bill, reorganization and restructuring of
existing government health care system, human resources and drug use amongst others.
A. Changes in financing
Changes in financing have been enacted through the establishment of Aspatal Kalyan
Samiti, under the Registration of Societies Act, at Zonal and District Hospitals. The
Government issued a letter on August 5, 2000 followed by a Government Order on July
8, 2001. These Samitis were set with an objective to improve system efficiency, service
quality; patient satisfaction; enhance local decisions and initiative of the officers; ensure
accountability at hospital level; enhance resource utilization and generate resources
through community financing and user charges. In terms of process, he shared that this
work which began in 2001 was attacked from all quarters. There was opposition as is
always there for any reforms measure. However, the results started showing in 2002-03
and people, now, appreciate the steps taken.
The Aspatal Kalyan Samiti has been extended to Sub-Divisional level Hospitals in 2002.
There exists provision for giving seed money to improve such facilities so that they add
to resource generation in the hospitals. Dr. Mahanta shared that encouraging results have
been seen. In terms of services, primary health care, emergency services. National
Disease Control Programmes as also entire treatment of families living below poverty
line is absolutely free. The criteria for families BPL are that they carry an Integrated
Rural Development Progamme (IRDP) card/certificate with them; or the treating doctor
is satisfied that the patient actually belongs to the BPL category. The major stakeholders
include the community and various non-governmental organizations (NGOs). In some of
the hospitals, the NGOs have adopted wards; they provide food to the indoor patients; are
involved in improving the infrastructure of the hospitals. The other stakeholders are the
Panchyati Raj Institutions (PRIs), district administration, patients and health providers. In
terms of the monitoring and evaluation system, monitoring is a regular process. One of
the members of the Samiti is a representative of the Audit and Accounts Wing of the
Finance Department. The evaluation of the working of these Samities upto the hospitals
at Zonal and District level were done by Himachal Pradesh Voluntary Health Association
(HPVHA). The recommendations of the report are being implemented in order to
improve the functioning of the hospitals.
34
Dr Mahanta also outlined the successes and failures, constraints faced and lessons learnt.
He said that it is clearly visible that where there are creative and dedicated in-charges of
hospitals, there the improvement in the hospitals is remarkable. However, the
improvement is State wide because it is for the first time that the doctors in the hospitals
have started developing a Vision for the hospital. The greatest hurdle in bringing about
changes is the employees of the Government, who vehemently opposed the formation the
Societies. They could come to terms after long deliberation with them. Another lesson is
that before jumping into a change or reform, all the stakeholders should be taken into
confidence after a series of discussions with them.
B. Health system organization, delivery and management
Another change attempted is in the area of health system organization, delivery and
management. These include granting of autonomy to hospitals, decentralization of
administrative and financial powers upto the primary health centre (PHC) level. The
Block Medical Officers (BMOs) have been given an imprest of Rs. 5000/- while the
Medical Officer In-charge (MO/Ic) of the primary health centres has been given an
imprest of Rs. 1000. However, in practice due to financial crunch the MO/Ic are not
enjoying this power as the funds are not placed at their disposal by the Block Medical
Officer. Dr. Mahanta stated that while delineating the role, one major step was the
functional integration of the Department of Indian System of Medicine and Homeopathy
and the Department of Health and Family Welfare to follow standard protocols in the
National Health Programmes. The same has been notified. The process was streamlined
in 2002-03 by putting into practice a defined methodology wherein District Ayurveda
Officers attend monthly meetings of the Chief Medical Officers (CMOs); the CMOs
allocate targets to the District Ayurveda Officers in preventive and National Health
Programmes. Meetings of sub-divisional Ayurveda Officers and Block Medical Officers
are held for determining targets for CHCs and PHCs; Officers have been appointed in
both the Directorates to solve the problems, if any. The training of Ayurveda officers in
National Health Programmes and other reforms is likely to be undertaken in Health and
Family Welfare Department, subject to availability of funds.
C. Role of Panchayati Raj Institutions (PRIs)
Another development is that the Panchayati Raj Institutions are being given adequate
powers to play a vital role in health related activities. Parivar Kalyan Salahkar Samiti
(PARIKAS) have been formed at all the three levels of Panchayati Raj System. The
Panchayat PARIKAS has Pradhan of Gram Panchayat as the President and, preferably,
the female health worker as the Secretary. The Khand PARIKAS has Chairperson of the
Panchayat Samiti as the President and the Block Medical Officer as the Secretary; and the
Zila PARIKAS has the Chairperson of the Zila as the President and the Chief Medical
Officer as the Secretary. Also sensitization workshops have been completed in 10
districts for the representatives of PRIs towards health related programmes. Workshops
for the representatives of the PRIs or 2 blocks are being held in Kangra District by Centre
for Research in Rural and Industrial Development (CRRID). A booklet giving details
about PARIKAS and health institutions plus health programmes has been published in
Hindi and it has been distributed to all the representatives of the PRIs. Funds for family
health awareness camps under HIV/AIDS and those for Mahila Swasthya Sangh
35
activities are being given to PARIKAS now instead of the Block medical Officers to
ensure more involvement of PRIs in health related activities.
D. Contracting out of services
Select support services in health institutions have been contracted out. Three support
services; viz., scavenging, laundry and diet are being transferred to the private sector,
wherever possible. The private sector is being involved in the service delivery only as far
as the National Health Programmes are concerned. There are some hospitals in the State
and four Hospitals outside the State where the employees of the State Government can
get their treatment done and the expenses reimbursed to them. Himachal Pradesh is also
attempting to appoint health care personnel on contractual appointment. As a part of this
process, the first step was to appoint institution-specific doctors. It was successfully done
and a three-day pre-placement training was given to these newly appointed Medical
Officers. The second step would be to fill 100 posts of doctors and 181 posts of nurses in
institutions where there is paucity of staff.
E. Promulgation of the Himachal Pradesh Paramedical Council Bill
Another change being attempted is the promulgation of the Himachal Pradesh
Paramedical Council Bill 2003. The objective is to maintain the State Register of
Paramedical practitioners and to prescribe a code of ethics for them; also to register paraclinical establishments etc. Efforts are also underway at promulgation of H.P. Medical
Council Bill 2003. A significant step in terms of policy has been the adoption of the
Himachal Health Vision 2020 by the government as a policy document, wherein it
commits to being the dominant provider of total health care services.
F- Reorganization and restructuring of existing government health care system
Another area of reforms pertains to reorganization and restructuring of existing
government health care system. Steps have been taken towards rationalization of health
institutions with staff being mentioned for each category of institutions. A revised
nomenclature of the health institutions in the State has been developed. Service Norms
for various health institutions have been notified and this would pave the way for “care of
a patient and the level at which he would be looked after”. Attempts are underway at re
structuring the cadre of Medical Officers in the service of the Directorate of Health and
Family Welfare.
G. Reforms related to human resources
In the area of human resources, state-wise cadre of laboratory technicians; pharmacists;
female and male health workers; dais (Birth Attendants) and staff nurses has been
converted into district cadre (Workforce Management). Secondly, all Health and Family
Welfare societies have been merged into one at the state and the district levels. Thirdly,
managerial skill up-gradation of senior level Officers has been done so that they prove
equal to the posts that they are likely to hold. Capacity building of Medical Officers in
proper utilization of the powers is being done along with the Reproductive and Child
Health programme refresher courses.
36
H. Drugs
In the area of rationalization of drug use, Essential Drug List, Drug Formulary and
Standard Treatment Guidelines have been prepared after the formulation of Essential
Drug Policy. Capacity building of Medical Officers in the use of generic drugs is
underway.
I. Other
Other improvements which have been attempted include, ensuring interconnectivity for
Management Information System for collecting data for National Health Programmes,
disease surveillance and manpower planning, which is currently being implemented on
pilot basis in select areas; improving information, education, communication (IEC) and
advocacy, streamlining the writing of annual confidential reports (ACRs), conducting a
survey on burden of disease, registration of vital events and its computerization. The
unfinished agenda has been documented in the Himachal Pradesh Health Vision.
37
5. Uttaranchal
Dr. I.S. Pal began his presentation by giving a profile of the State of Uttaranchal, relating
to its population, administrative and health care delivery structure. He outlined the issues
of accessibility of health care due to the physical terrain, geographical locale of the state
and lack of infrastructure and human power. Thereafter, he described the reforms being
attempted in the health sector at the primary and secondary levels of care.
A. Reform initiatives at the primary level
The reform initiatives for primary health service delivery consist of contractual
appointments of medical officers and Auxiliary Nurse Midwives (ANMs), especially in
the remote areas to combat the problem of access to health services, development of a
transfer policy for medical officers again aiming to ensure availability of service
providers in remote areas. The medical officers posted in remote areas are given
preference for post graduate admissions during service, specialists are appointed in the
community health centres / Tehsil and district hospitals. The other areas are training of
birth attendants, provision of incentives like a special non practicing allowance to service
providers in difficult areas. Amalgamation with the Integrated Child Development
Scheme (ICDS) by training Anganwadi workers (AWWs), holding joint meeting with
medical department at district, block and sector levels are some other measures being
adopted. Similar kind of integration with the Indian System of Medicine and
Homeopathy (ISM&H) by involving them in implementation of National Health
Programme and establishing linkages between this department and the health department
at sector, block and district levels is also underway. To ensure better management of
human resources, a fixed day schedule for health service delivery has been drawn up.
Also, the powers and responsibilities of medical officers at additional primary health
centres have been fixed. Community participation in health service delivery is being
attempted through a pilot project planned with the support of the Sector Investment
Programme. In the realm of public private partnerships, mobile van is being provided for
diagnostic and curative services in collaboration with the department of Science &
Technology and the Birla Institute of Scientific Research.
B. Reform initiatives for secondary health service delivery
Reform initiatives for secondary health service delivery include privatization of
sanitation, laundry & diet services. A government order to hand over laundry and diet
services in nine hospitals to private agencies was passed in December 2001. The agencies
were selected based on competitive bidding. Disease specific diet is being served in these
hospitals. The services in the Doon hospital were handed over to the private agencies in
February 2003. Another area of partnerships with the private sector has been
establishment of public calling offices (PCOs) in government hospitals. The other
initiative includes formulation of a drug procurement policy. A state comprehensive
policy is to be formulated by the Uttaranchal Health System Development Project
(UAHSDP). With a view to bring about decentralization and ensure community
participation, Chikitsa Prabandhan Samitees have been established in select hospitals.
These committees have been registered for 30 district level hospitals under the
38
chairmanship of the District Magistrate. Elected members are represented in the samitees.
100 percent of the user fees collected is retained by the Samitees for utilization.
Initiatives have been taken to establish integrated umbrella society at state and district
level. At the state level, apex society for National Programme has been established under
the Chairmanship of Chief Secretary to ensure implementation of National Health
Programmes. Furthermore, six sub-committees have been set up under the chairmanship
of secretary medical for various national programmes with the Director General as vice
president. The funds flow from the Government of India through the state level society to
district empowered committees for implementation of National Programmes. A.
secretariat is proposed to be setup in the campus of Director General with support for
manpower and equipment. At the District level, district empowered societies have been
registered. The committee is headed by the District Magistrate with the Chief Medical
Officer as Vice President. Similarly, to the state level, even at the district level, a
secretariat is proposed to be set up.
At the policy level, an integrated health and population policy was formulated in
December 2002, outlining specific health and population stabilization objectives, policy
directions and interventions to achieve the mission and policy objectives. Lastly, Dr Pal
spoke of the proposed delegation of powers under the 73rd Amendment wherein the Gram
Panchayat would have administrative control of male and female workers at village level.
In the future, recruitment would be made through the gram panchayat. The block
panchayat would have administrative control of all health delivery personnel at block
level. Again, future recruitments except for medical officers would be through the block
panchayat. The Chairman of the Zila Parishad would have administrative control at
district level with the Chief Medical Officer functioning as the Additional Executive
Officer.
39
6. From First Phase to Second Phase of RCH
Ms. Nandita Chatteijee shared the initiatives being planned under the second phase of the
Reproductive and Child Health (RCH) programme, which is presently being designed.
The first phase of RCH programme would close by March 2004 and presently efforts are
underway for designing the second phase of the RCH programme. Based on past
experiences, some of the lessons learnt include, criticality of state ownership of the
programme, need for flexibility based on state needs and capacities, for adequate
institutional arrangements to be put in place, for upfront agreement on process and output
indicators, insistence on regularity and quality of monitoring systems, linking of
performance to financing, establishing linkage between the reproductive and child health
programme and family planning services, strengthening of management capacity in the
areas of planning, supervision, budgeting and fund flow, strengthening of program
management capacity at district levels especially in the Empowered Action Group (EAG)
states, need for introduction of human resource planning, forecasting requirements of
human resources, their training, posting and promotional policies. The other lessons
include, need to establish client sensitive behavior in service providers, developing state
specific behavioral change strategies, enhancing client responsiveness to the reproductive
and child health services so as to introduce a demand driven service delivery system,
improving outreach services, particularly regarding routine care and in retaining clients
for completing the cycle of care, involving coihmiihitiesrfarid; local elected bodies in
planning, management and monitoring of program performance, inclusion and emphasis
on neonatal health & adolescent health, involvement of private sector to enhance
availability of services and to build bridges with other critical sectors.
Ms. Chatterjee also outlined the need for the second phase of the RCH programme in
view of the high level of Infant Mortality Rate (IMR) and contribution of neonatal
mortality, the need to focus on states with high total fertility rate (TFR), to address
inequities in the use of service delivery systems related to child health, maternal health
and essential obstetric care in the weak states, to improve functional linkages of primary
care services with facilities providing emergency obstetric care (EOC) and better
understanding of contributory factors through maternal death audits and the need to
improve birth spacing, skilled attendance during pregnancy, care and service during child
birth and post natal periods.
The vision of the Second Phase of the RCH programme is to bring about outcomes as
envisioned in the National Population Policy 2000(NPP 2000), The Tenth Plan
Document, National Health Policy 2002 (NHP 2002) and Vision 2020 India, minimizing
regional variations in the areas of Reproductive and Child Health and Population
Stabilization through an integrated, focused, participatory program meeting the unmet
demands of the target population, and provision of assured, equitable, responsive quality
services, by adopting a mission mode. Further, the programme, also aims to educate and
empower through behaviour change communication and community mobilization in
improving the health seeking behaviour, to increase quality/responsive/sensitive/reliable
service availability and improve the accessibility in order to improve the attendance at the
40
public health system, to set in motion sector reform initiatives in order that the service
availability in the public health delivery system achieve a better perceived image among
the population, to put in place strategic initiatives to bring about a wider role for the
private sector providers to enable achievement of wider reach of services and to initiate
policy changes to ensure assured services at all levels in a equitable manner to all those
who seek services as well as enable initiatives hither to not possible due to the policy
environment.
The proposed strategies for the same include provision of dedicated structural
arrangements to improve program management, improved ownership among states,
decentralized planning and implementation through involvement of the Panchayati Raj
Institutions (PRIs) and Urban local bodies (ULBs), strengthened system of planning,
monitoring and supervision, adopting a differential approach, integrating referral
networks, strengthening quality aspects of service delivery, enhancing coverage of
antenatal care, new bom care, institutional deliveries, bringing comprehensive integration
of family planning into safe motherhood and child health, inter-sectoral collaboration and
convergence, empowering structure and enabling environment and increasing the
involvement of the private sector.
The various components of the programme would include maternal health, reproductive
tract infections / sexually transmitted infection, new bom and child health, adolescent
health, population stabilization, urban health, tribal health, involvement of non
governmental organisations, infrastructure mapping & strengthening, behavioral change
communication and training.
The process of designing this programme for a state would include the formation of a
design team with a nodal official to lead the process, drawing experts from the state itself,
looking at outputs upfront, interpolating process indicators and working out annual plans
and budgetary requirements, conducting a sector analysis, monitoring on the basis of
performance benchmarks as agreed upon mutually by the state and the Ministry of Health
& Family Welfare (MOH&FW), drawing on good practices and attempting
decentralization through the PRIs or ULBs.
41
Remarks by Resource Persons
1. Shri Javid Chowdhury, Former Secretary Health, Ministry of Health & Family
Welfare
At the outset, Shri Chowdhury expressed unease at the use of the term, ‘health system
reforms.’ He was of the view that the health scenario keeps changing from time to time. It
may improve or deteriorate due to various reasons like interventions by the state or
private practitioners. To cope with this changing scenario, various initiatives have to be
modified from time to time and these initiatives may be called reforms. In his remarks,
he spoke of the significant features of the health scenario in India today, which would
have a bearing on the reforms or initiatives to be undertaken.
Shri Chowdhury began by addressing the issue of accessibility of health services. He
opined that the services available to the citizens of this country are highly inadequate. He
based his views on the findings of the National Sample Survey (NSS), 1995-96 study
which indicates that as many as 16.4 percent of people who fall ill, do not have any
access to health services, mainly due to want of financial resources and for want of access
to a health delivery centre nearby. The fact that this occurs in a country where at least 26
percent of the population lives below the poverty line; he felt is a matter of serious
concern.
The second issue that Shri Chowdhury spoke of related to public and private health
expenditure incurred in the health sector. The public expenditure of Rs. 200 per capita
(US $4) per year is miniscule. This expenditure as percentage to GDP is 1 percent, which
is amongst the lowest in the globe. On the other hand, the private expenditure is about Rs.
800 per capita per year. This expenditure though not very low, is very sporadically
spread. Hence in times of availability of funds, an individual may seek good treatment at
fairly high cost while non-availability of the same may lead to serious ailments being
untreated. This composition of low public health expenditure and sporadic private
expenditure provides no health security in India.
Shri Chowdhury laid emphasis on the need to examine the responsibilities assigned to
public administrators and the increased reliance placed on private practitioners,
institutions and private service providers. The National Sample Survey Organisation
(NSSO) data has shown that though public health expenditure is very low, the public
health services are largely utilized and accessed by those below the poverty line or those
marginally above it. The high proportion of private expenditure on health and utilization
of private sector is partly due to the limited availability of public health services. He
disagreed with the general perception that if given a choice, people would avoid public
health services and opined that people avoid these services, as no service exists.
Therefore, he said that the expenditure being made in public health services is not a dead
loss; it is a mode of service delivery which cannot be ruled out.
Further, he added that the fact that private services cost more than those provided in
publicly funded institutions is an aspect which cannot be forgotten in the process of
42
formulating a policy and discussing how to develop a mix between public and private
sector to achieve the goal of ensuring reasonable health services to the population.
Shri Chowdhury then raised the issue of lack of monitoring of quality of health services
and the lack of any professional standards or ethics. This in light of the dominant role of
the private health sector was seen by him as an area of concern. While issues of lack of
quality crop up in the public sector too, there exist mechanisms for ensuring some
standards in the public institutions thereby making it unlikely that the situation would
become as exploitative as it might in an unmonitored private health delivery system.
He clearly stated that he was not assuming any conffontationist role between the public
and private sector but merely trying to identify the characteristics of the two modes of
delivery so as to assess the extent to which they could be enhanced. He was of the view
that the unmet need for medical services in the country is so great that even if both these
sectors stretch themselves out fully, there would still be a substantial unmet need. In this
context, he offered some suggestions as to what would possibly be a reform direction that
one could adopt to mitigate the current situation.
The initiative taken to delegate powers and resource raising authority to local self
government institutions under the 73rd and 74th Amendment have a significant bearing
and need to be strengthened. The second initiative is the greater association of private
practitioners and private service providers in public health programmes. To illustrate, the
vertical programmes for control of tuberculosis and malaria can be implemented through
private practitioners and private service delivery centres. Therefore, partnership in such
activities Shri Chowdhury felt would be very fruitful and should be adopted at the
earliest. He proposed that other programmes like immunization, prenatal and post natal
supervision of the mother and children, also be implemented through the channel of the
private practitioners and private service delivery centres. These would increase the outlets
enormously, particularly in the urban areas. The partnership with the private sector as an
outlet for health services funded by the state could also be adopted.
Moving to the area of insurance, Shri Chowdhury opined that it is currently estimated
that 107 million people are covered by way of voluntary social health insurance,
mandatory insurance or private insurance. It is felt that in the medium range this is not
likely to grow to more than 165 - 170 million. So out of one billion population, 170
million would be serviced by some type of health security. Given this position, the
question that needs to be addressed is where would the rest of the people go? This in turn
necessitates a larger role for the state, in spite of the prevailing constraints. He also
brought out the lack of any operational research and base data relating to health insurance
and the information gap pertaining to what types of modes of service delivery would be
effective in different situations and in different parts of the country.
Thereafter, Shri Chowdhury drew attention to the fact that the non-governmental
organisations (NGOs) operating voluntary social insurance schemes are doing an
admirable job but within a limited span of operation. It would then be unrealistic to
expect this mode of service provision to lead to complete coverage. He suggested that
43
one needed to take up small blocks, provide funds and a package of primary health care
services of say Rs. 150 per capita, per year. This could be entrusted to the PHCs, so that
one is able to ascertain, based on field experiences, as to what is ‘doable’. He also spoke
of alternative financing. Shn Choudhury’s view was that the scope for alternative
financing is relatively low in India. He questioned that if 83 percent of health expenditure
is privately funded then what more can one expect from the private sector? He was of the
view that there existed a possibility of obtaining better value for it and one of the
mechanisms would be risk-pooling. The private insurance which exists is applicable only
for a limited section. Therefore, he suggested it would be useful to carry out experiments
for implementing social health insurance in compact blocks, which could be funded by
the state in say 50 PHCs on a pilot basis. A minimum health package would need to be
defined; operations would need to be reviewed to see if these are viable. The modules can
be of different parameters to ensure that we strive towards an optimal solution.
He felt that any talk of health sector reforms, should also include budgetary reforms.
There cannot be any talk of improving organizations without having the basic inputs.
Given the low levels of allocation of resources, he felt that the public health system has
not been optimally tried out. He hoped that the policy prescription contained in the
National Health Policy 2002 of increasing public health expenditure to 2 percent of the
Gross Domestic Product (GDP) by 2010 would lead to improvements in the performance
of the public health providers. Lastly, he stated that while the concept of health sector
reforms is being pushed by developed countries, they are also realizing that providing
advice without any support is not likely to be expected.
2. Dr. Tej Walia, Adviser, HSD, WHO-SEARO
Dr Walia traced the process of health sector reforms and highlighted some critical issues
of concern. He opined that health sector reforms is an ongoing process in the South Asian
region, and its beginnings can be traced to the Alma Ata Declaration and the call for
Health for All (HFA), using primary health care as mechanism for delivering ‘Health for
AIT. Health sector reforms have been taking place in a piecemeal manner not only across
different states in India but also globally and some of these experiences have been
recorded. There have been some successes from the health sector reform process, with an
improvement in health indices over the last 30 years but an unfinished agenda still exists.
Prior to the reform process, in the 1960s, most governments were more focused on
economic development and hoped that it would lead to a trickle down effect. Later, it was
realized that this was not necessarily the case, so focus in the second stage turned to the
reaching those who were not being reached such as the poor, the underprivileged and the
focus also shifted to the rural areas. Currently, the emphasis is on health and poverty,
wherein publication of reports like the Commission on Macroeconomics and Health, have
provided a new impetus to this process. However, the call for health sector reforms has
been voiced not from within the health sector but from the outside. The bilateral and
multilateral agencies have been calling for reforms as many of the basic elements of
primary health care have not been addressed at the peripheral level. Also, from the
government side, economic pressures, dwindling resources and need for rationalization of
44
health care delivery, financing of public sector are some of the other issues which have
given an impetus to the process of reform.
Dr. Walia stressed the fact that the government is no longer in a position to provide free
health care to the entire populous of this country, with increasing population, lack of
resources, increased provision and financing by the private sector, which is primarily
involved only in curative care. This calls for a public-private mix. The various problems
associated with the private sector, its burgeoning growth outside the scrutiny of the public
sector necessitates that the government plays a stewardship role and brings the private
sector into provisioning of health care along with the public sector. Dr Walia also brought
out the fact that we tend to focus our discussion of health sector reforms on the public
sector alone, thereby leaving out opportunities for capacity building of non-governmental
organisations (NGOs) and the private sector. Also, as health goes beyond health sector
reforms, we need to foster new partnerships with other sectors like environment, water,
transport. We also need to strengthen existing partnerships while simultaneously
maintaining the leadership role. The other issue, he addressed pertained to how best to
provide services to the under-privileged and the poor. The need for community based
health care has emerged clearly. While it is crucial, to go down to the community level,
certain pre-requisites need to be met. Measures need to be taken to develop local
leadership; there is a need to look at decentralization process, locate appropriate
technology at that level and to look at sustained mechanisms for partnership. He also
brought out the fact that health sector reform demands links between policy makers and
decision makers, has to involve the planners, the economists and the researchers. There
is need to ensure optimal use of research findings on guiding health sector reforms.
3. Sunil Nandraj, NPO, EIP, WHO-India Office
At outset, Shri Nandraj remarked that it was an eye-opener to listen to the experiences of
the States and the various initiatives taken by them in a proactive manner. He stated that
the need to change felt by the states (which itself may be due to several reasons) is a
positive development. He raised the question, whether health sector reforms is the latest
‘buzz’ word and emphasized the need to define health sector reforms in the Indian
context, as each person has assigned different meanings to this term. Shri Nandraj,
illustrated that the usage of the term, public-private partnership, is another oft-used word
in the health sector today, defined differently by each State. In one State, it may take the
form of handing over a public hospital to the private sector while in another, services may
be contracted out to the private sector under the realm of partnership or primary health
centres (PHCs) may be handed over to non-governmental organisations (NGOs). He
opined that the term ‘partnership’ implies similarity in objectives and raised the question,
where the public and private sector had similar objectives and whether we have attempted
to match the two. He was of the view that right now, it appears as if the private sector is
bestowing favours on the public sector by involving itself in health care delivery.
He also brought out the fact that many states tend to classify routine matters as health
sector reforms and remarked that much of the presentations of state experiences have
focused on the content rather process of reforms. There is need to undertake process
45
documentation of these reforms in the Indian context. This is significant, as it would
enable States to share and learn from each other’s experiences and mistakes. The other
issue that we need to gain clarity on is what to reform. Moreover, given, the dominant
role of the private sector, health sector reform should include the private sector. He
shared experiences of different states in regulation of private sector through enactment of
a law, some successful while others facing stiff opposition by different lobbies and hence
continuing as draft bills, awaiting clearance from the Legislature. There is also lack of
adequate data on the private sector, in terms of number of hospitals, etc. He felt that there
is a need to examine the health sector as a whole with the government clearly defining its
role either as a financer or provider or administrator or all three. These issues he felt are
important in the light of emphasis being laid on public private partnerships. Given the
past experiences at enacting legislation for the private sector, there is a need to examine
new mechanisms such as accreditation to improve the quality of health services. These
mechanisms could be linked to insurance and the new incentives such as those announced
by the Ministry of Finance. Partnerships can be entered into with accredited providers,
which in turn would ensure minimum standard of care to the patient.
Another issue raised was the role of various stakeholders in the process of health sector
reforms. Terms like user charges, contracting out, and decentralization are increasingly
being used. But who is initiating these changes. There is lack of evidence as to whether
these initiatives are having the desired impact. It is pertinent that one reviews these
initiatives and assesses its impact.
He concluded by stating that the present workshop was a good beginning for us to
document, and learn from each other and hoped that the Ministry would ensure wide
scale dissemination of the documentation.
4. Dr. Indrani Gupta, Associate Prof. Institute of Economic Growth
Dr Gupta presented her views as a researcher and economist. She began by raising the
question, whether states were really engaged in health sector reforms or were essentially
carrying on innovations, which we may want to term as reforms. She expressed
discomfort at the repeated use of the word ‘reform’ as it essentially means revamping,
undertaking of major changes. She also brought up the fact that we might feel that if we
are not undertaking these changes, then we are failing. The term health sector reforms,
has been around for several years, and unfortunately tends to largely conjure up images
of the World Bank and user fees. This, she felt was unfortunate as health sector reforms
encompasses many other things. She expressed the view that a series of innovations are
occurring at the state level on a continuous basis and these could occur in any sector.
The second issue raised by her was that some of the bilateral and multilateral donors had
stepped in and seem to have influenced the agenda in the health sector. Dr. Gupta opined
that they have probably filled an existing vacuum. This is especially so, in light of the
divide which exists between the Centre and the States. In her opinion, although the
Centre has not played a proactive role in terms of dialogue during the reform process, the
dialogues have occurred essentially between the World Bank and the Centre, in spite of
.!
46
health being a state subject. The states have been left behind in this process and
understandably various agencies have filled a vacuum which should not have existed in
the first place.
Dr. Gupta was of the view that we need to utilize whatever option may work, whether it
is public private partnership, decentralization, user fees in a state or district as long as it is
consistent with the principles of health sector equity and efficiency. In the area of
resource allocation, on one hand, we need to allocate more to the health sector, and the
initiative for the same needs to the come from the Centre as well as the States.
Simultaneously, we need to ensure that the existing resources are being spent efficiently
and equitably.
She pointed out the fact that the states had not focused on evaluation and brought out the
need to monitor and assess whether a reform is working - administratively, financially
and outcome-wise. This would necessitate having a system in place for data collection, in
a format which can be utilized at a later point to assess whether the ‘innovation’ has
worked. Based on her experience, she emphasized the need to bring about management
and administrative changes in the health sector.
Lastly, she concluded by saying that this was the first time , she had an opportunity to be
present at a workshop where experiences from the state were being shared and this she
felt was a very encouraging sign. So also was the fact that at the state level, there are
efforts underway to re-evaluate its own health needs and priorities. Each state would then
formulate its own innovations and reforms. If the Centre helped the States on prioritizing
their innovations, then in her opinion it would be a great step forward.
5. Dr Rama Baru, Associate Professor, Jawaharlal Nehru University
Dr Baru felt that it was a very heartening experience to listen to the presentations made
by the various states and to learn about the various initiatives undertaken. She too,
expressed the view, that it might be more appropriate to use the word, "innovations’
rather than "reforms’. While the presentations of the states, clearly brought out that there
are elements of reform, it appears that states are attempting various innovations, which in
itself is a heartening process. Based on the presentations of the various states, she felt that
elements of reforms are common across states, while the emphasis differs with some
focusing more on financing while others on infrastructure. She lauded the fact that
emphasis is slowly being given to other areas which support the heath services and not on
provisioning alone. The other issue raised by her, related to the need to create evidence
and the importance of this workshop in that direction. She felt that it is very important to
have evidence if one would like to study the innovations and scientifically evaluate them.
6. Shri J. P. Misra, EC Health & Family Welfare Sector Programme in India
Shri Misra mentioned that the reforms in the public sector essentially began in the 1990s.
He shared the experience of the EC Health & Family Welfare Sector Programme in
47
conducting two workshops on this issue, in Delhi and Kufri with the State Health
Secretaries. He brought up the need to further examine the reform initiatives in depth, as
they may appear to be very significant on the surface and reiterated the need to back up
the initiatives by building capacities to undertake these activities. The basket of reform
initiatives more or less, include elements of decentralization, user fees, etc. There is a
need to examine whether these intentions have actually been implemented and what may
be the possible factors which may hinder effective implementation. He based his
observations, on his experience of working in the state of Uttaranchal, amongst others.
The other issue raised by him pertained to the capacity of the system to absorb all the
existing resources and the need to strengthen the same. He also shared information about
the initiative of the Sector programme in bringing out a Policy Reforms Options Database
(PROD), which aims to enable exchange of information.
Other remarks, suggestions and issues raised
❖ It was felt that any talk of health sector reforms should favour the poor. They should
be at the centre of any reform process and the key question that we need to address is
how to make the health services more equitable.
❖ One of the suggestions to enable sharing of information across states was to evolve a
web based forum / web site. Apart from a website where information about reform
initiatives would be available, a framework or template for the same needs to be
developed, such that it allows individual experiences to also emerge.
❖ There appears to be lack of sharing amongst the various government departments and
programmes, both at the centre and state level and there is a need to evolve a
mechanism to enable the same, to avoid duplication and to contribute to mutual
efforts.
❖ Capacities need to be built at the State level, to analyze data and emerging trends
rather than encourage reliance on external experts.
❖ There is a need for content as well as process documentation of health sector reform
initiatives underway in India.
❖ It was brought out that prior to talking about health sector reforms, there is a need to
ensure health improvement in communities and efficiency, equity, quality,
sustainability and client responsiveness. Health sector reforms would entail a
fundamental change. There is a need to look at both technological and managerial
improvements in the health sector.
❖ The need to examine the role of various medical colleges, universities, research
institutions in the health sector reform process, especially prior to the initiation of
reforms was brought out. They can be involved in conducting feasibility studies and
initial assessments. The feasibility of initiatives like user charges, decentralization,
should be assessed, particularly from the perspective of the community.
48
Synopsis of Day 1
Ms. Anagha Khot, WHO National Consultant, Ministry of Health & Family Welfare,
presented a synopsis of the proceedings of the first day of the workshop. She outlined
the main points made by the various speakers. The points made by the various speakers
clearly brought out the following issues.
There is a need to define health sector reforms in the Indian context. The questions raised
were, ‘are we really engaged in health sector reforms? Or are innovations being
undertaken in terms of health planning and provisioning of services?’ There is a need to
distinguish normal incremental changes from reforms and define the parameters which
would be used to distinguish between the two. Secondly, emphasis should be laid on the
process of reforms along with the content. Lack of adequate process documentation of
health sector reforms in India was identified as one of the gaps. Further studies would be
required across various components of health sector reforms to assess their impact and to
emulate the ‘success’ stories and learn from failures. Furthermore, monitoring and
evaluation mechanisms need to be incorporated right from the point of initiation of
reforms. Adequate mechanisms for collecting data for review and documentation need to
be built into the process of reforms. The state presentations clearly brought out the
plurality of experiences among the states as far as health sector reforms are concerned.
There is a need to learn from these experiences as to what works as a reform and the
possible obstacles that one may face and to ensure participation of all stakeholders in the
reform process from its conception. Capacity building of stakeholders at different levels
is another critical area of concern. The discussion clearly brought out the need for the
Centre to play a more pro-active role in the area of health sector reforms and for all
present to define the way forward.
49
Group Work
The participants were divided into two pre-determined groups. The issues for group work
were:
Group 1: Definition of health sector reforms & the next steps
Group 2: The content of reforms & the next steps
Definition of health sector reforms
The group began by examining the definitions of health sector reforms (Refer to
Background Paper: India’s Health System: Role of Health Sector Reforms). The
definitions given by Berman, 1995 & Cassels, 1995 were examined in depth. It was felt
that these definitions were too generic in nature and could be applied to reforms in any
sector and was not necessarily confined to health sector reforms. Also, being generic in
nature, these definitions could not be operationalized.
During the course of discussion, the perceptions of the various group members about
health
reforms
’■:±T sector
----f---- j were discussed. The group felt that the definition and content of
health sector reforms are interlinked. The group discussed what should be the different
elements of health sector reforms, its guiding principles and how the same could be
operationalized. Based on the deliberations and the experiences of various States, the
following matrix to examine health sector reforms in India was suggested. It was felt that
the same matrix could also be used to evaluate the reforms at a further point.
Issues
Matrix to define health sector reforms in India
_________ Guiding Principles________________
_______ Equity
Efficiency
Quality
Sustainability
Regulation of private sector
User charges______________
Institutional reform for financing
Statutory control of quality &
minimum infrastructure norms for
service provision
Evidence
based
policy
and
programme __________
Strategies to enhance quality public
sector_______________
Strengthening of primary health care
Financing of consumables (E.g.
drugs at PHC)___________
Hospital Autonomy
Even distribution of manpower
Accountability
Content of health sector reforms
The group felt that prior to looking at the content of reforms, there is need to define the
same. Based on the presentations made by the various states, it was felt broadly, health
sector reforms would include elements of administration / governance, financing,
provisioning. The group was of the view that it should not outline the specific elements
50
within each of these, as it would restrict the states and that the same should be defined by
the States.
Suggested next steps
Group 1
■ Need to clearly state at the policy level, as to what would constitute reforms and
guiding principles for the same. A need for a state health policy was expressed by
representatives of various states.
■ Need for process documentation of the initiatives taken. This in turn would
provide a methodological framework which could be used to evaluate health
sector reforms against some agreed set of principles.
■ Sharing of experiences and information across states. Apart from the web, maybe
states need to visit each other. A related issue was that while there is agreement
that such sharing needs to take place, need to address who would fund such an
initiative. A question asked was whether consolidated donor funding with donors
from each state can contribute to such an endeavour.
■ Need for an institutional mechanism to enable sharing between states as well as
the state and the centre
■ It was suggested that an institution be identified as a nodal point for undertaking
such review and documentation. The other view was that the Ministry itself can
serve as a nodal point, network and co-ordinate with the states.
■ Donor agencies working in the States should be involved in the health sector
reform process and they should engage in capacity building at the state and
regional level.
Group 2
The group tried to define roles for the centre and the state.
Role of the Centre:
❖ In house dissemination of information relating to health sector reforms.
❖ Provision of experience sharing platform for the States
❖ Informing states of experiences that have worked through: (a) Research studies, (b)
Documentation, (c) Creation of a specific unit in the Ministry of Health, which would
collect information on various ongoing reform experiences and to ensure its sharing.
❖ Providing guidelines for health sector reforms, for each of its components and to
facilitate technical guidance, capacity building, facilitating and funding interstate
visits.
❖ Involving other Ministries like Ministry of Finance while addressing reform issues
like health financing.
Role of the State:
❖ Identification of a nodal officer in each State to coordinate activities of health sector
reforms and to liaise with the unit at the centre
❖ Organization of a state level workshop for all categories of State level officers
❖ Inclusion of health sector reforms in Annual Plan and Five Year Plans
51
pH -130p03
Open Discussion
Based on the group presentations the following issues were raised.
❖ One of the questions posed was, given the plurality of experiences, priorities and
norms prevailing in different states, how can comparison of experiences be ensured,
using a standard procedure or system? In response, it was felt that establishing certain
benchmarks and common guiding principles would assist in such a comparison,
though the content of reforms may vary across States.
❖ Need to empirically examine whether a programme or initiative has done well and
this information then needs to be widely disseminated. The issue itself may be
amenable to quantitative or qualitative examination.
❖ While there is a need to talk of macro level policies, there is simultaneously a need
for policies at micro level
❖ The funding obtained from donor agencies should be treated as an additionality to the
budget and not form a part of the consolidated fund.
❖ Need to define a role for the civil society in the reform process.
❖ The ideological overloading or abstractness while defining health sector reform has to
remain.
❖ There is a need to examine possibility of composite funding rather than programme
specific funding.
❖ In terms of any evaluation, need to be clear about its purpose. The aim should be
constructive and to draw lessons. The evaluation process needs to be institutionalized
as a learning process. Furthermore, need to ensure that the institution / individual
undertaking the evaluations have appropriate experience and capacity to undertake
such work. Instead of conducting evaluation through external organizations, there is a
need to encourage development of internal systems for a constant stream of data
collection and analysis for correction purposes as well as to ascertain whether the
reforms have trickled down to the lowest level. If one does not have internal
evaluation system to support reform initiative, it carries the risk of being termed as a
failure while the cause ultimately lies in poor management
❖ Need to document and share positive experiences with each other.
❖ States should be assisted to evaluate their priorities before launching any reforms and
the centre can play a crucial role in this.
❖ Need for the centre to co-ordinate the involvement of different donor agencies and to
define the priorities rather than each donor deciding which states they want to work
in.
❖ Need to take this process forward by setting up a nodal officer at state level, and
centre.
❖ Need for better co-ordination between the centre and the state.
❖ Much of the documentation pertaining to health sector reforms is being done by
multi-lateral and bi-lateral agencies and this is not-easily available. There is a need to
demand some transparency in this process.
To summarize, the discussions clearly brought out the need for ensuring ongoing sharing
of reform initiatives between the Centre and the State as well as amongst the States. It
was felt that the Centre needs to act as a nodal agency and play a critical and proactive
52
role in this regard. A beginning could be made by having in-house sharing of views and
experiences in the Central Ministry itself. While providing a platform for sharing of
experiences, the Centre also needs to engage in capacity building initiatives. At the State
level, suggestions relating to assigning a nodal officer to co-ordinate health sector reform
initiatives, holding workshops with officers, inclusion of health sector reforms as part of
the Five Year Plans were made. The need for co-ordinated donor assistance was a
common issue raised by the groups. The group also stressed upon the urgent need for
documenting and evolving a framework / methodology to ensure comparison of reform
initiatives across States.
53
CONCLUDING REMARKS
Concluding Remarks by Shri Javid Chowdhury & Smt. P. Jyoti Rao
As part of the concluding remarks, Shri Javid Chowdhury shared his thoughts on the
proceedings of the one and half day workshop. He felt that the workshop was educative
and provided a forum to learn about the various initiatives taken by the states. The states
are reacting based on their own priorities; some more pro-actively while others less so.
But essentially they are reforming and are bringing out changes in a sequence which their
system and political environment can accept. He was of the view that such a workshop
sensitizes and shows that certain things are possible with significant impact.
Secondly, Shri Chowdhury brought out the necessity of evidence based evaluation. He
saw the lack of in-house database / expertise as a hindering factor. He stated that there
have been instances when the project evaluations conducted by various agencies have not
been upto the mark. At the same time he stressed that one should not wait to build a
corpus of research database, but begin with what is available and further develop the
same. Even in terms of reforms, he felt that without getting over-awed by lack of
understanding or by the fact that one has not thought out the reform to the last detail
conceptually, all states and practitioners would be well advised in their areas to launch
reforms.
Given the fact that implementation of reforms leading to change is a long process, he
encouraged all policy makers and other stakeholders not to loose heart and to persist in
the achievement of reform goals and objectives. He stressed the importance of achieving
various milestones along this process, to enable sustenance interest, enthusiasm and
morale of the group. Based on his experience wherein good schemes were planned
elaborately over ages but also steam by the time they were implemented, he urged that
any reform idea be pushed ahead with small changes or innovations as long as it was
coherent with the larger picture envisaged for the health sector in India.
Thereafter, Smt. P Jyoti Rao_thanked the participants. She voiced the view that while one
had not worked out definitions of health sector reforms, the broad parameters had been
defined in the due course of discussions. She emphasized the need for each one present to
introspect within their own spheres of activity to assess whether there was any scope for
structural change within the system as well as implementation of reform initiatives. In her
view, health sector reforms should be concerned with larger paradigm shifts and
structural issues. She regarded the present workshop as an opportunity to contemplate on
how little changes can be brought about and how few innovative practices could make the
system perform better within the given constraints. She welcomed the suggestion made
about the need for having a small cell or unit at the ministry which would essentially
function as a networking outfit as well as engage in collection and dissemination of
information pertaining to health sector reforms. She mentioned that the deliberations of
this workshop would be documented intensively and assured of such interaction at
regular periods to ensure continuity in the process. Given, the complicated nature of the
health sector no one intervention by itself would make a difference as there are a range of
issues and multiple steps would be needed. On behalf of the Centre, she committed,
within the given constraints to complete the required documentation, do the networking
54
and be on look out for success stories and failures and ensure its wide scale
dissemination. She felt that the purpose of this workshop has been served as one had got
more sensitized to this area, and assured of such interactions to take place at shorter
periodicity.
J.
55
ANNEXURE
Agenda
MINISTRY OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF INDIA
NEW DELHI
Workshop on
India’s Health System: Role of Health Sector Reforms
September 4-5, 2003
Time
____ Tentative Time Schedule & Agenda_______
Theme
__________________________
Date / Day: September 4, 2003 Thursday
9.15-9.30
Registration
9.30-9.40
Address
Smt P Jyoti Rao
Additional Secretary, Health
9.40-10.00
Address
Dr. Prema Ramachandran
Planning Commission
10.00-10.10
Address
Shri P. Hota
Secretary, Family Welfare
10.10-10.20
Address
Smt. Malati Sinha
Secretary, ISM&H
10.20-10.30
Address
Dr. S.J.Habayeb
WHO-WR India
10.30-10.40
Address
10.40-11.00
Coffee/Tea
Dr. S. P Agarwal
Director General
Health Services
56
Working Session I
11.00- 11.20
Overview of health sector reforms:
International & national experiences
Dr. Rama Baru
11.20-11.40
Remarks
Shri Javid Chowdhury
Health Sector Reform initiatives across States
11.40-12.00
Punjab
Dr. Anjali Bhawra
12.00-12.20
Rajasthan
Dr. B. Sekhar
12.20-12.40
Observations & Analysis
Dr. Tej Walia
12.40- 1.00
Observations & Analysis
Shri Sunil Nandraj
1.00- 1.20
Discussion
1.20- 2.00
Lunch
Working Session II:
HSR initiatives across States continues
2.00 - 2.20
Gujarat
Shri S.K. Nanda
2.20 - 2.40
Himachal Pradesh
Dr. R.N. Mahanta
2.40 - 3.00
Observations & Analysis
Dr. Indrani Gupta
3.00-3.20
Observations & Analysis
Dr. Rama Baru
3.20-3.40
Discussion
3.40-4.00
Coffee/Tea
Working Session III: HSR initiatives across States continues
4.00-4.20
Uttaranchal
Dr. LS. Pal
4.20 - 4.40
From First Phase to Second Phase of RCH
Ms. Nandita Chatterjee
4.40-5.00
Observations & Analysis
Shri J. P. Mishra
5.00-5.30
Discussion
57
Date / Day: September 5, 2003 Friday
9.30 - 9.40 Synopsis of proceedings of Day 1
Ms. Anagha Khot
Working Session IV: Group Discussion
9.40-11.15
Group Work
(Working definition for health sector reforms in the Indian context.
Content and process of reforms, Next steps)
11.15-11.30
Coffee / Tea
Working Session V:
Next Steps
11.30-12.15
Presentation of group discussion
12.15 -12.30
Discussion
12.30 - 1.00 Concluding remarks
Next Steps
Shri Javid Chowdhury
Smt. P. Jyoti Rao
Lunch
58
Background Paper
Health Sector Reforms: The Indian Scenario
Background Paper
Workshop
On
India's Health System: Role of Health Sector Reforms
September 4-5, 2003
India International Centre
New Delhi
Bureau of Planning
Ministry of Health & Family Welfare
Government of India, New Delhi
In collaboration with
World Health Organization
New Delhi
Draft: Not to be cited
HEALTH SECTOR REFORMS: THE INDIAN SCENARIO
Objective of the paper. This paper endeavors to define health sector reform, list its
content and forms. Further it attempts to identify the rationale and goals of health
reform and to ascertain key issues / challenges for future planning and implementation
of health reforms in the Indian context.
Introduction
'Health sector reform' has been the subject of increasing attention and is an often-used
word in the health parlance today. The last two decades have seen health sector reforms
emerge as a major issue on the policy agenda. Despite different levels of income,
institutional structures, and historical experiences, many countries in recent years, have
embarked on health sector reform in varying degrees. A wide range of contextual factors
including the macroeconomic situation, the political environment, the societal values
and external influences affect the development of health sector reform in a particular
country.
The genesis of health sector reforms can be traced to the early 1980s. Prior to the 1980s,
health care provision was mainly publicly funded and organized through public health
care services with the aim of improving equity in access to care. However, the 1980s saw
a smaller role emerge for the State and a shift to a neo-classical paradigm. In face of
world recession, the oil shock of the late 1970s, the socio political changes that occurred
globally especially after the collapse of the Soviet Union, a fiscal crunch was felt by both
developed and developing countries. As a consequence of the economic crisis of the
early 1980s, there was a change in the economic policies of several developing countries.
This situation was coupled with governments struggling to develop financing
mechanisms in the context of severe income inequalities, low access and utilization of
health services by the poor, overburdening of existing services due to diseases such as
AIDS and rising communicable as well as non communicable diseases. During this
period, social sectors like education and health were increasingly squeezed financially
and cutbacks were made in the state intervention in the health sector. The fiscal
constraints coupled with pressure on health systems due to rising health needs led to
many countries availing of loans from the "Bretton Woods" institutions namely the
World Bank and the International Monetary Fund, under the Structural Adjustment
Programme.
Thus, during the period of 1980s to mid 1990s, health sector reforms were an attempt to
respond to the serious challenges posed by the collapsing health service delivery
systems in many poor countries and reforms were particularly concerned with re
defining the relationships between the state, service providers, users and other health
related organizations (Standing H, 2002). One of the foremost documents highlighting
the change in role for the government and the enforcement of a new paradigm was
60
Draft: Not to be cited
'Financing Health Services in Developing Countries' brought out by the World Bank in
1987. This document led to the Bank placing health financing at the centre of its policy
dialogue with borrowers. This paper proposed four reforms: implementation of user
charges at government health facilities; introduction of insurance or other risk coverage;
usage of nongovernmental resources in a more effective manner, and introduction of
decentralized planning, budgeting, and purchasing for government health services.
In terms of the overall macro environment, by mid- 1990s, shifts began to occur in the
pattern of international aid, bilateral aid budgets continued to decline as a total
proportion of international transfers to the poor countries. There was however, an
increase in the proportion of loans from multilateral agencies, particularly for social
expenditures such as health. This was in part due to the concern being expressed over
the impact of structural adjustment programmes on the social sectors. This period saw a
move away from donor specific project funding to sector investment programmes and
approaches (SWAPs). There was a more broad based thinking not only on the technical
aspects of reforms but also on needs and concerns of users and the importance of
involving a wide range of stakeholders. Trends towards decentralization, continued
growth and use of private provision of health services persisted, leading to an emphasis
on governance, accountability and regulatory issues. (Standing H, 2002).
A path breaking document the World Development Report (WDR), 1993 titled, 'Investing
in Health', provided the blueprint for health sector reform for developing countries. This
paradigm included changes in the conceptualization, planning, and delivery of health
services, apart from new ways of health financing. The WDR 1993 proposed a three
pronged approach to government policies for improving health. These include: (A)
Fostering an environment that enables households to improve health (B) Improving
government spending on health (C) Promoting diversity and competition. The overall
role envisaged for the government was that of promoting economic growth. The report
visualized that the government would pursue economic growth policies that benefit the
poor, expand investment in schooling, particularly for girls, promoting the rights and
status of women through political and economic empowerment. It also recommended
improvement in government spending on health in a manner that benefits the poor. The
methods suggested included reduction of government expenditures on tertiary facilities,
specialist training; implementation of user fees to affluent patients using the government
hospitals and services, financing and implementing a package of public health
interventions and essential clinical services and improving the management of
government health services through measures such as decentralization of administrative
and budgetary authority and contracting out of services. It suggested adoption of
policies which encouraged social or private insurance for clinical services outside the
purview of essential services being provided by the government, encouragement of
suppliers, both in private and public sector to compete both to deliver clinical services
and to provide inputs to publicly and privately financed health services. Generation and
dissemination of information of provider performance was also seen as a crucial role
61
Draft: Not to be cited
which needed to be performed by the government. With the publication of this
document, the mid-1990s saw an increasing emphasis on assessment of priority health,
with the global burden of disease analysis and associated priority setting methodologies
becoming the recommended basis for planning and allocating health expenditure. This
led to the development of basic packages and interventions based on assessments of
greatest health needs and on maximum gain per unit of expenditure. Acknowledging
the fact that the private sector was emerging as one of the main players in the health
sector, attention was accorded to ways of regulating and harnessing the private sector in
health delivery, thereby leading to experiments in contracting out of services amongst
others.
The late 1990s to 2000s has seen the re-emergence of poverty as a global concern in the
macro economic fora. Health has again come to occupy an important place in the
international aid agenda, in view of the close linkages between poverty and health. This
period has seen the emergence of initiatives like the Commission on Macro Economics
and Health, development of poverty reduction strategy papers (PRSPs) and the
Millennium Development Goals (MDGs) as well as the emergence of new international
financing mechanisms like the Global Fund to fight AIDS, Tuberculosis and Malaria, the
Gates Foundation amongst others. While financial and institutional reforms, regulation
have continued to be important issues in the health reform process, increasing stress is
being laid on governance and accountability issues. The underlying conditions
necessary for economic and social development and the role of governments as
regulator and in the context of multiple players and interests is assuming increasing
significance. This has meant a greater role for the civil society in developing mechanisms
to hold the governments as well as service providers accountable. (Standing H, 2002)
Hence, it can be seen that there have been different generation of reforms, which differ
subtly in its emphasis and premises. For example, while the first generation of
adjustment policies ascribed importance to the stabilization measures, the secondgeneration of reforms focused on structural and institutional issues. The current thirdgeneration adjustment policies are placing a special emphasis on poverty reduction,
transparency, accountability and democracy.
Prior to delving into the content of health sector reforms, it is pertinent to address key
questions like, 'What do we mean by reform?', 'What are the essential components of
reforms?' 'How do reforms differ from normal evolutionary and incremental system
changes?'
Definition of health sector reforms
The term 'reform' has become increasingly popular during the last few years, yet there is
no consistent and universally accepted definition of what constitutes health sector
reform thereby leading to varied meanings and connotations. Reform essentially
62
Draft: Not to be cited
involves change that affects goals, strategies, institutions, services and human
behaviour. Some of the definitions put forth are stated below:
❖ The current wave of interest in changing the policies, practices and management
systems within the health sector is often referred to as health sector reform. Berman
describes health sector reform as 'sustained, purposeful change to improve the
efficiency, equity and effectiveness of the health sector' (Berman, 1995)
*♦* Cassels defines health sector reform as activities concerned with changing health
policies and the institutions through which these are implemented. Redefining
policy objectives alone is not enough, d o deal with health sector constraints, there is
a need for institutional reform with changes to existing institutions, organizational
structures and management systems. Thus, health care reform is concerned with
"defining priorities, refining policies and reforming the institutions through which
those policies are implemented." (Cassels, 1995 cited in Figueras J et al, 1997)
<♦ Health sector reform is a sustained process of fundamental change in policy and
institutional arrangements of the health sector, usually guided by the government.
The process lays down a set of policy measures covering the four main core
functions of the health system, viz. governance, provision, financing and resource
generation. It is designed to improve the functioning and performance of the health
sector and ultimately the health status of the people. Health sector reform deals with
equity, efficiency, quality, and financing and also defines the priorities, refining the
polices and reforming the institutions through which policies are implemented
(WHO, 1997)
❖ A reform is defined as a process that involves sustained and profound institutional
and structural change led by government and seeking to attain a series of explicit
policy objectives (Figueras J et al, 1997)
❖ Health sector reform can be defined as 'a process that seeks changes in health sector
policies, financing, and organization of services, as well as in the role of government,
to reach national health objectives.' Reform is a process and not a one-time event or
decision and involves changes intended for the long term, not ad hoc or emergency
solutions to address crises. "Sector reform" is by definition sector-wide in that it
affects more than one service, supply, or clinical policy, and more than one facility,
provider, institution, or geographic location. In the course of this long-term process,
reforms require midterm assessments and corrections. (Change & Population Council,
1998)
*:• Health sector reform in the Region of the Americas has been defined as a process
aimed at introducing substantive changes into different health sector entities and
63
Draft: Not to be cited
functions with a view to increasing the equity of their benefits, the efficiency of their
management, and the effectiveness of their actions and, thereby, meeting the health
needs of the population. It involves intensive transformation of the health systems,
carried out during a given period of time and justified by circumstances that make it
a viable undertaking. (PAHO)
❖ Health sector reform is the systematic redesign of the role of the public sector in the
organization, provision and financing of health services and the design and
implementation of the structures and financing strategies needed to effect these
changes (Rosenthal as cited in Johnson S, 2000)
Thus, health sector reforms are "sustained purposeful processes of fundamental change
in the policy and institutional arrangements in the health sector".
Firstly, it is essential to specify what is meant by "fundamental" change. Fundamental
change means that it must make a real or significant different in the way things work
over time. William Hsiao (as cited in Berman & Bossert, 2000) specifies a set of "control
knobs" that determine the major processes and outcomes of health care systems. Hsiao's
framework implies that the major focus of health sector reform efforts is to establish, set,
or adjust these control knobs of financing, payment, organization, regulation, and
consumer behavior. It may be useful to distinguish more strategic and fundamental
programs of system change from those that are more limited, partial, or incremental.
The former might be called "big R" reforms and the latter "little R" reforms. The "big R"
reforms are those that involve at least two or more of Hsiao's control knobs in programs
that affect a substantial part of the health care system. "Little R" reforms are those that
address only one control knob with a more limited scope of change. For example,
establishing a new or greatly expanded system of national health insurance should
properly involve substantial changes in financing, regulation, and delivery. Depending
on how these are structured, they would significantly affect the organization of health
care delivery as well. This would qualify as a “big R" reform. In contrast, "small R"
reforms would include the introduction of user charges in public clinics or granting of
autonomy to the national teaching hospital. Such efforts can have important benefits, to
be sure, but in isolation they are not of the same scope or degree of difficulty as the "big
R" changes. While a "big R" reform may involve the implementation of many "small R"
activities, it is the broad systemic package that makes a "big R" implementation more
that the sum of its "small R" parts. Secondly, it is stated that the reform should be
"purposeful." Purposeful effort implies that there are clearly defined objectives,
strategies for achieving those objectives and efforts to monitor change and modify
strategies as needed. The elements and components of the reform need to have been
developed in a rational manner: identifying clearly the problems of the health systems—
evidence-based —and linking the mechanisms of system change to solving those
problems. A clearly articulated policy of health reform is required so that major actors
responsible for implementing the change can specify goals and objectives, acknowledge
64
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the relationship of their activities to achieving the goals of reform, and the purposeful
linkage among different components of system change. Third, is that the reform should
be "sustainable." Most fundamental changes will be sustained because they involve
significant transformation of systems and the creation of actors who will defend their
new interests in the political process. However, reforms that are passed by legislation
and not implemented would not qualify; nor would failed reform efforts that are later
reversed. For instance, the ambitious "managed competition" reforms of the Netherlands
were not sustainable—they were never fully implemented and the reform laws were
amended to remove most of the anticipated system changes. The respective
governments usually guide the reform processes on a technical and political basis. They
are designed to improve the functioning and performance of the health sector and,
ultimately, the health status of the population.
While it is unlikely that one definition would be able to capture all the nuances of the
different types of change strategies in the health sector, it is essential to identify the key
elements that could be used to characterize health sector reform. Figueras J et al, (1997)
have described the following framework.
Key elements of a framework for health sector reform
Process
•
Structural rather than incremental or evolutionary change
•
Change in policy objectives followed by institutional change, rather than
redefinition of objectives alone
•
Purposive rather than haphazard change
•
Sustained and long term rather than one off change
•
Political top down process led by national, regional or local governments
Content
•
Diversity in measures adopted
•
Determination by country specific characteristics of health systems
To sum, health sector reform is deliberate, planned and intended to make long term,
permanent changes, rather than ad hoc or emergency action. It is about seeking
solutions to major problems in a country's health care system and involves many actors,
institutions and stakeholders. While most of the health sector problems that reformers
identify tend to be relatively 'technical', solutions require much more than developing or
applying the 'right' technical answer. Designing and implementing health sector reform
is a preeminently political process. Hence, health sector reform deals with equity,
efficiency, quality, financing and sustainability in the provision of health care and also in
defining the priorities, refining the policies, and reforming the institutions through
which policies are implemented. It is a process of change involving the what, who and
65
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how of health sector action, and generally forms part of a bigger reform taking place in
the public sector (WHO, 2002)
Manifestations / forms of health sector reforms
The content of reforms is a complex process. There is no universal 'package' of
measures, which would constitute health sector reforms, and reforms have tended to
assume varied forms across various countries. But review of literature indicates that
reforms often tend to be initiated by the Ministries of Health with the aim of deliberately
effecting a change in the health policy of the government with a view towards
improving its performance. The reforms attempt to ensure the strengthening of the
health policy and planning functions, introduction of organizational changes, new
management policies and practices, defining national, regional and local-level disease
priorities, setting standards for provision of health care, developing appropriate systems
for monitoring performance (including quality assurance initiatives) and introducing
effective health interventions. (WHO, 1997) Hence, it can be said that reforms tend to
cover four core functions of the health system viz. governance, provision, financing and
resource generation. Some of the approaches adopted for classification of reforms are
given below.
Changes in financing methods
❖ User charges;
❖ Community financing schemes;
❖ Insurance (social, private, compulsory insurance, community risk sharing schemes);
❖ Stimulating private sector growth; and
❖ Increased resources to health sector.
Changes in health system organization and management
❖ Decentralization
❖ Contracting out of services; and
❖ Reviewing the public-private mix.
Public Sector Reform
❖ Downsizing the public sector;
❖ Productivity improvement;
❖ Introduction of competition;
❖ Improving geographic coverage;
❖ Increasing role of local government; and
❖ Targeting role of public sector through
packages of essential services.
............................................................. Thomason (1997)
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Reforms in Policy and Organization, including health care financing: Health policy
changes, allocative efficiency, changes in health financing mechanisms, management
and organizational changes, privatization in health care
Reforms for improving health care delivery: Changes in development and / or
deployment of human resources for health, strengthening district health systems,
essential health care package(s), selective v/s integrated health care.
Reforms beyond the health sector: Decentralization, intra- and inter-sectoral actions,
community action, health care market promotion and international investment.
.............. ..............................................................................
(WHO, 1997)
Frenk (as cited in Berman, 1995) identifies four policy levels for reform action: the
systemic, programmatic, organizational and instrumental. The systemic level of policy
action addresses organizing and managing the linkages between the major actors in the
system including the institutional arrangements. The programmatic level addresses
what the health service actors do while organizational level focuses on the how of health
care provision, addresses issues related to quality of care and productivity. The
instrumental level refers to policies for collection and use of health systems information,
for research and technology, development and for the development of human resources
and other inputs for health care.
Hence, the most widespread elements of health sector reform include (Mills, 2001):
■ Restructuring of public sector organizations (including decentralization and
bureaucratic commercialization whereby publicly owned facilities are restructured
so that they run more along the lines of privately owned establishments, in the
health sector this is usually termed hospital autonomy or 'corporatisation').
■ Changing the way in which resources are allocated and paid to both organizations
and individuals, generally with the aim of creating a clearer link between
performance and reward
Encouraging greater plurality and competition in the provision of health care
services through policy measures such as liberalizing the private health sector and
contracting with or subsidizing private health providers
■ Seeking increased financing for health care from non tax revenue sources such as
user fees, social health insurance and private health insurance
Increasing the role of the consumer in the health system through enhancing the
power and scope of consumer choice and making health providers more accountable
to community based organizations such as hospital boards.
While the earlier section has outlined the content of health sector reforms, it is crucial to
outline what are the goals and principles of health sector reform.
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Goals & Principles of health sector reform
The various approaches to reform process are underlined by different goals. Improved
planning and management by making decision making more responsive to local needs,
improved service organization by reducing duplication of service provision, increased
accountability by introducing clearer lines of accountability at all levels and promoting
participation are common objectives of reform process (Gilson L & Mills A, 1995) The
goals of health sector reform, in a formal sense, remain the achievement of efficiency,
improving quality, preserving or promoting equity, and generating new resources for
health care, sustainability of the health sector and the organizations and institutions that
comprise it. Hence, most reform measures are meant to ensure that an appropriate share
of public funds (overall government expenditure) is spent on health care, or there is an
equitable distribution of public health expenditure across all levels of care or there is an
appropriate mix of public and private spending in health development (i.e. allocative
efficiency). The users have to be satisfied with both the form and content of health
services offered (i.e. improved health status and client satisfaction) and the benefits of
publicly funded health care (including preventive health interventions) are also
equitably distributed (i.e. improved equity of access to care)(WHO, Nov. 1997)
Preconditions for successful reforms
Ensuring the success of the various reforms and the reform process, would necessitate
the fulfillment of certain pre-conditions. The national capacity to plan and manage the
process of change would be the first requisite. This would include training and
development of human resources, improving the capability of individuals and
institutions to carry out the expected tasks, capacity building of government as well as
non-governmental structures, establishment of and / or linkages with autonomous
institutions for strategic studies and policy analysis amongst others. Continuous
monitoring and review of the content as well as process would increase the likelihood of
'successful' reforms, thereby meeting the goals behind the initiation of reforms.
Health sector reform in India
Economic liberalization in India can be traced to late 1970s. However, it was only in 1991
that reforms began in earnest. Dwindling foreign reserves, negative growth of exports,
soaring inflation, culmination of fiscal profligacy during the 1980s, high cost import
substitution policies coupled with a balance of payments crisis set off by the Gulf War
opened the way for an International Monetary Fund (IMF) program that led to the
acceptance of a major reform package. The situation was compounded by a quick
succession of changing governments. This was coupled with a realization which had'
been gaining ground in policy making circles that a major change of economic system
was needed and led to the initiation of a wide ranging programme of reform. The
program which consisted of stabilization-cum structural adjustment measures was put
in place with a view to attain macroeconomic stability and higher rates of economic
growth (Bajpai 2002). This occurred in a larger deteriorating public health scenario,
wherein on hand, communicable diseases persisted and some of them like malaria
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developed insecticide resistant vectors while others like Tuberculosis were increasingly
becoming drug resistant, HIV / AIDS was assuming extremely virulent proportion. On
the other hand, non-communicable diseases were arising as a result of life style changes
and increase in life expectancy.
Hence, in the Indian context, reforms per se were necessitated as it was felt that in spite
of some gains, the earlier regulatory model of development, had not delivered the
expected results. These reforms sought to achieve rapid economic development, to
improve the living standards of the people and ensure their development, to eliminate
poverty, to protect human rights and to ensure people's participation, especially that of
excluded groups. These reforms aimed at closing the gap between India's potential and
actual performance. The essence of the reforms has been to increase the productivity of
all sections of the society by making competition free and access to markets easier.
(Economic Advisory Council, GOT). Though India's reforms have been piecemeal and
incremental, the reforms of the last decade have gone a long way towards freeing up the
domestic economy from state control. State monopoly has been abolished in virtually all
sectors, which have been opened to the private sector. The impact of policy trends
towards greater deregulation, liberalization and integration with the global economy
has been felt in the health sector too.
Content of health sector reforms in India
In India, there has been a gradual shift in the organization, structure and delivery of
health care services. Some of the important policy shifts as enumerated in the Eighth,
Ninth and Tenth Five Year plans are described below (Eighth, Ninth& Tenth Five Year
Plan Documents, Govt, of India)
The Eighth Five Year Plan (1992-1997) was the first plan document wherein the need for
re-structuring of economic management systems, following the macro developments of
the 1990s was stated. In terms of health reforms, during this period, the concept of free
medical care was revoked and people were required to pay, even if partially, for the
health services, thereby leading to the levying of user charges from people above the
poverty line for the diagnostic and curative services offered in health institutions. The
scheme was so designed as to ensure free access or highly subsidized access to the
needy. Furthermore, other initiatives with the private sector were encouraged.
The Ninth Five Year Plan (1997-2002): The Ninth Plan emphasized the need to review
the response of the public, voluntary and private sector health care providers as well as
the population themselves to the changing health scenario, to reorganize health services
so that they become efficient and effective and to introduce health system reforms to
enable the population to obtain optimum care at affordable cost. The suggested health
system reforms broadly fall into three categories: structural, functional and governance
related. It was envisaged that the public sector would play a lead role in health system
reforms. The Tenth Five Year Plan (2002-2007) touches upon reforms at primary.
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secondary and tertiary level. The suggested reforms are similar to those mentioned in
the Ninth Five Year Plan.
In terms of structural reforms, the Plans envisaged reorganization and restructuring of
all the elements of health care so that they function as integral components of a
multiprofessional health system. In terms of functional reforms, it envisaged that efforts
be made to improve efficiency by creating a health system with well defined hierarchy
and functional referral linkages. The suggested categories of reforms: structural &
functional, financial or resource related and governance related are detailed below.
Structural & Functional Reforms:
■ Reorganization and restructuring of existing health care infrastructure including the
infrastructure for delivering ISM&H services at primary, secondary and tertiary care
levels , so that they have the responsibility of serving population residing in a well
defined area and have appropriate referral linkages with each other.
■ Human resource development to meet growing health care needs - adequate in
number, with appropriate skills and attitudes.
■ Skill up gradation of health care providers through CME and redeployment of the
existing health manpower so that they can take care of the existing and emerging
health problems at primary, secondary and tertiary care levels.
■ Horizontal integration of current vertical programmes including supplies,
monitoring, IEC, training and administrative arrangements; formation of a single
health and family welfare society at state and district levels.
■ Fully functional accurate reporting system which provides data on births, deaths,
diseases and data pertaining to ongoing programme through service channels,
within existing infrastructure; monitoring and evaluation of these reports and
appropriate midcourse correction to be done at district level;
■ Building up an effective system of disease surveillance and response at district, state
and national level within and as a part of existing health services;
■ Building up efficient and effective logistic system for supply of drug, vaccines and
consumables based on the need and utilization.
Financial Reforms I Resource related reforms:
■ Continued commitment to provide essential primary health care, emergency life
saving services, services under the National disease control programmes and the
National Family Welfare programme totally free of cost to individuals based on their
needs and not on their ability to pay
■ Evolve, test and implement suitable strategies for levying user charges for health
care services from people above poverty line while providing free service to people
below poverty line; utilize the collected funds locally to improve quality of care.
■ Evolve and implement a mechanism to ensure sustainability of ongoing govt,
funded health and family welfare programme especially those with substantial
external assistance.
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■
Working out cost of diagnosis and therapeutic procedures for major and minor
ailment in different levels of care and setting cost of care norms.
The Ninth Plan envisaged that major public health priorities such as essential primary
health care, emergency life saving services, services under the disease control and family
welfare programmes would be provided free of cost for all. Further, it advocated that
the Centre and the state governments work out appropriate norms for levying user
charges on people above the poverty line for other services and hospitalization and
evolve mechanisms for collection and utilization of funds. It is recognized that health
sector reforms during the Tenth Plan address the issues of equity and need and devise a
targeting mechanism by which people below poverty line have ready access to
subsidized health services to meet their essential health care needs; simultaneously
efforts be made to build up an appropriate mechanism of payment for health care by
other segments of population. Simultaneously, there is a need to explore mechanisms
for providing near-universal coverage of the population for meeting the cost^ of
hospitalization and continuous care for chronic disease. Health finance options may
include health insurance for individuals, institutions, industries and social insurance for
below poverty line (BPL) families.
Governance related
Introduce a range of comprehensive regulations prescribing minimum requirements
of qualified staff, conditions for carrying out specialized interventions and a set of
established procedures for quality assurance.
Evolving standard protocols for care for various illnesses at primary, secondary and
tertiary care settings — public sector hospitals, medical colleges, professional
associations to play a major role in this exercise.
a Quality assurance and redressal mechanism such as Consumer Protection Act and
Citizens' Charter for hospitals are to be set up.
- Appropriate delegation of powers to Panchayati Raj Institutions (PRIs) so that the
problems of absenteeism and poor performance can be sorted out locally and
primary health care personnel function as an effective team.
a
Involvement of the Panchayati Raj Institutions in the planning and monitoring of
ongoing programmes and making timely corrections for optimal utilization of
services.
Efforts are under way to bring about quality assurance and accountability in health care
services. Many states are setting norms for posting of medical personnel in rural areas,
and ensuring transparency in these so as to bring about accountability regarding
presence and performance of health care providers (Planning Commission, Annual Report
2002-03). To illustrate. West Bengal has demarcated the state into three zones, and has
provided for posting of medical officers in these zones for a fixed period. The state has
District Health and Family Welfare Samiti', so that various committees and societies do
not act at cross purposes. All public health functions are controlled by the CMOH. A
71
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system performance has been developed to identify the performance of different
categories of employees and all the donor partners supporting the state health
department are brought under a donor partner's coordination committee headed by the
chief secretary to improve coordination. In Uttaranchal special incentives are being
given to doctors posted in remote areas with difficult terrain. Tour programmes of the
ANMs are fixed in advance and MCH clinics are conducted on fixed days, and
immunization days are also fixed. Sectoral and block level meetings are held every
month. The deputy CMO pays surprise visits to these meetings whenever he can. In
Nagaland the medical officer of every PHC is directed to visit every sub-centre once a
month. The ANM is required to live there, and her tour is fixed in advance. She has a list
of hospitals where different specialists are available, so that she can direct the people
appropriately in an emergency. A booklet listing all the villages under each PHC/sub
centre is available with the Village Health Committee. In case the service providers are
absent from their duties, their salaries are deducted and used for up gradation of health
care services there. Uttar Pradesh is planning to give special incentives to doctors
willing to work in rural areas e.g. giving urban houses for their families, creation of a
specialists' cadre etc. MBBS doctors will have to serve in the rural areas for a specified
period before being eligible for an urban posting.
Another area where reforms have been underway pertains to public - private
participation in health care. A wide variety of public-private collaborative efforts have
been reported by different States.
a
a
d
d
a
Ongoing experiments involving private sector practitioners in the National
Programmes (E.g. Mahavir Hospital, Hyderabad in DOTS programme in Andhra
Pradesh, involvement of private practitioners/ institutions in blindness control
programme, utilization of NGOs and not- for- profit institutions in leprosy and
HIV/AIDS programme)
In states where private practices for Govt, doctor is allowed, 80% of the doctors in
government services, practice either in their own private clinic or work in a private
clinic as a consultant.
In some states the private practitioners either in modern medicine or ISM&H are
given the responsibility of manning a primary health care centre where government
doctor is not available; these contract physicians need orientation training so that
they can fulfill the role expected of PHC physicians in preventive, promotive and
curative care as well as implementation of national programmes.
Private practitioners especially specialists are hired on contract to provide specialist
care in primary health centre/community health centre under RCH Programme, to
improve access to RCH services for "at risk" women and children. Districts engage
services of private doctors for performing MTPs
Private sector individuals/institutions e.g. Tata Iron & Steel Company (TISCO)
provide health care to the population living in a defined area.
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d
Private sector institutions e.g. companies contribute to meet health care needs of a
population living in the vicinity of their factory.
d Private superspeciality, tertiary/secondary care hospitals were given permission to
import equipment without duty with the understanding that they will provide in
patient/out-patient services to poor patients free of charge.
d Private super-speciality, tertiary/secondary care hospitals were given land, water
and electricity etc. at a concessional rate with the understanding that they will
provide in-patient/out-patient services free of charge to BPL patients.
d Private practitioners provide information for disease surveillance in some districts in
Kerala.
d Part time hiring of general practitioners and specialists to visit and provide health
care in PHCs/CHCs in under-served areas e. g., Madhya Pradesh;
d Private agencies have been engaged for support services like kitchen, laundry,
cleaning and security (E.g. West Bengal, Maharashtra, Uttranchal, Gujarat),
d States are inviting private sector to set-up medical colleges (E.g. West Bengal).
The impact of all these on improving access to health care at affordable cost and
improving control of communicable diseases have not yet been evaluated. However,
available information suggests that these schemes had succeeded in places where there
was a well defined committed group to ensure that the MOUs were implemented fully.
It is important that public/private participation should be area specific taking into
account the health care needs of the population, presence of each of these sectors, their
strength and weaknesses. Monitoring of implementation with participation of the PRI
and local leaders will go a long way in ensuring accountability. The Ninth Plan period
also saw the initiation of various collaborations between the private and public sector
institutions. The Tenth Plan aims to build on the recommendations of the Ninth Plan
and take up on a priority basis, documentation of such collaborations between private
sector and public sector institutions and the role each of them play in outpatient/
inpatient health care in different districts/states. Attempts would also be made to
improve area-specific public-private collaborations, taking into account the health care
needs of the population, the presence of each of these sectors, their strengths and
weaknesses. Feasibility of GIS mapping to identify under-served areas and providing
suitable incentives to encourage private sector to set up health facilities in such areas
will be explored. During the Tenth Plan appropriate policy initiatives would be taken to
define the role of government, private and voluntary sectors in meeting the growing
health care needs of the population at an affordable cost
Reforms initiatives in the Department of Family Welfare
The Department of Family Welfare has also made efforts to enhance the quality and
coverage of family welfare services through increased participation of general medical
practitioners working in voluntary, private, joint sectors and the active cooperation of
practitioners of ISM&H. Panchayati Raj Institutions (PRIs) have been involved with a
view to ensure inter-sectoral coordination and community participation in planning.
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Draft: Not to be cited
monitoring and management of the RCH programme. The PRIs would assist the states
in supervising the functioning of health care related infrastructure and manpower and
ensure coordination of activities of workers of different departments such as Health,
Family Welfare, ICDS, Social Welfare and Education and functioning at village, block
and district levels.
Under the RCH programme, several initiatives were taken to improve collaboration
between the public and private sectors in providing family welfare services to the poor,
especially in the under-served areas. Efforts were made to increase the involvement of
private medical practitioners in RCH care by providing them orientation training and
ensuring that they have ready access to contraceptives, drugs and vaccines free of
cost. Various NGOs are being encouraged to participate in RCH programme. The
Department on project basis involves NGOs in programmes such as introducing Baby
Friendly Practices in hospitals, for advocacy of RCH and family welfare practices and
for counselling. The Department of Family Welfare funds mother NGOs (larger NGOs
looking after smaller ones) covering 412 districts and over 800 NGOs. These NGOs cover
all districts in ten states. The state governments have also been trying to involve NGOs
in providing services, or adopting a PHC. The results have been mixed; these
experiments need to be carefully monitored. The Department of Family Welfare has
also proposed that the NGOs who have adequate expertise and experience may
participate in RCH service delivery. The Tenth Plan calls for undertaking policy
initiatives which increase public-private-voluntary sector collaborations to meet the
health care needs of the poor and vulnerable segments of population and monitor and
enforce regulations and contractual obligations amongst others.
Health Sector Reform initiatives across select States
In face of problems like suboptimal functional status and difficulties in providing
adequate investments for improving health care facilities in the public sector, almost all
the state governments have introduced health system reforms. There are substantial
differences in the content and extent of the reform. Several States have obtained external
assistance to augment their own resources for initiation of health sector reforms in their
State. All States utilize funds from BMS, ACA for PMGY and EAP to fill critical gaps in
manpower and facilities. One of the major reform initiatives is the Secondary Health
System Strengthening Project funded by the World Bank in seven states (Andhra
Pradesh, Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). The
focus in this project is on strengthening FRUs/CHCs and district hospitals to improve
availability of emergency care services to patients near their residence and reduce
overcrowding at district and tertiary care hospitals. The States have reported progress in
construction works, procurement of equipment, increased availability of ambulances,
drugs; improvement in quality of services following skill upgradation training in clinical
management, changes in attitudes and behaviour of health care providers; reduction in
mismatches in health personnel / infrastructure; improvement in hospital waste
management, disease surveillance and response system. All the States have also
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attempted introduction of user charges for diagnostic and therapeutic services from
people above poverty line with varying degree of success. (Planning Commission,
Annual Report, 2002-03)
Health sector reform initiatives undertaken or underway across the States of Andhra
Pradesh, Delhi, Kerala, Madhya Pradesh, Orissa, Rajasthan, TamilNadu, Gujarat,
Himachal Pradesh and Tripura are described below. (Planning Commission, Annual
Report 2001-02& 2002-03; response to Questionnaire on Health Sector Reforms)
Andhra Pradesh: Some of the major initiatives include:
a Strengthening of the Primary Health care infrastructure under the Andhra Pradesh
Economic Rehabilitation Project, which includes the provision of buildings,
additional staff training and recurring expenditure.
a A system of community health care workers has been set up to improve access to
health care for tribal population.
a Volunteers covering 20 families act as link between community and health care
providers.
a Filling critical manpower gaps in medical officers and certain para medical staff on
contract basis for a period of one year through district-based recruitment.
d Setting up of Advisory Committees to improve community participation, and
monitor quality of services in Sub Centre, PHCs, CHCs, Civil Hospital and district
hospitals.
a
a
a
a
a
a
a
a
a
A system of Hospital Advisory Committees to provide for greater autonomy and
accountability at hospital level has been formed.
Hospital Development Societies have been formed in all tertiary level hospitals in
the State which are under the control of Director of Medical Education.
Strengthening and upgradation of 150 first referral units under World Bank
assisted Secondary Health systems project, which also includes strengthening of civil
infrastructure, equipment, additional staff and has a provision for meeting recurring
expenditure.
Centralized system of procurement of drugs for all government institutions has
been put in place.
Privatization of non medical services (E.g. security, cleaning in all hospitals).
Pilot project of handing over one Primary Health Centre (PHC) each in the tribal
areas to NGOs
Private sector is encouraged to set up medical and dental colleges and
paraprofessional training institutions.
A transparent policy for posting of personnel based on merit and on grading given
through the performance monitoring system has been finalized. Medical and
Paramedical personnel serving in remote rural and tribal areas are given special
incentives.
District population stabilization societies are formed, and authority and funds were
devolved to local levels.
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Gujarat: Reforms underway in the State of Gujarat are
d Project undertaken for creation of Block Health Office to assist District Health
Organization
a Scheme proposed for creation of Community based health volunteers in urban
areas.
d To ease the problem of vacancies of specialists in health and medical services,
honorary and part time specialists are being appointed. Private practitioners are
encouraged to provide services in public sector under the 'Samaydan scheme'.
d Management of PHCs and CHCs has been undertaken in partnership with NGOs.
Primary health care services have been handed over to SEWA-Rural.
d Link Couple Scheme has been approved for the rural areas. Under this scheme, ten
couples married during last five years and having aptitude for social work would be
sleeved from villages where the post of ANM is vacant or ANM is not staying in the
HO. They would act as a link between the service provider and the community.
d Grouping of CHCs has been done, so as to ensure that at least 4 specialists are
available in these CHCs. This has necessitated rearranging posts of specialists from
low performing CHCs, PP Units, etc.
d Emergency obstetric care services have been established in tribal and inaccessible
areas. A pilot project would be implemented in one Taluka.
d Application of GIS in planning of activities related to malaria control.
d Proposal to implement Quality Control Circles to improve quality of health care
services by means of capacity building in one Taluka.
d Services have been contracted out for developing strategies and implementing key
IEC project in malaria control.
d In RCH training, the training is being imparted by inviting faculty on task related
contact system. Similar system is followed for training and research for HIV control
programme.
d Re-organization of entire cadre of para medical ophthalmic assistant (PMOA)
d Powers have been delegated to medical officers to undertake minor repair work in
PHC/SC buildings. These powers are limited to grants received from donor agencies.
Similar powers delegated for civil works to District RH societies.
d Networking of blood banks operated by government, trust hospitals and by private
owners would be done.
d Urban health care project is proposed under the 12th Finance Commission for
providing primary health care to urban slum population under public private
partnership.
d Mapping of expertise available for training in private and NGO sector and
involving them in training and sharing of information, (e.g. Integrated Disease
Surveillance)
Himachal Pradesh: Himachal Pradesh has initiated reforms in the following areas
d User fees introduced in hospitals from the zonal to sub-divisional levels.
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d
d
d
d
d
d
d
d
d
d
d
d
d
d
d
d
Administrative and financial powers right up to PHC level have been
decentralized. PARIKAS (Parivar Kalyan Salahkar Samiti) has been formed at all
three levels of Panchayati Raj System.
Autonomy has been granted to hospitals / health institutions
Select services such as scavenging, laundry and diet have been contracted out. The
responsibility of security of hospitals has been entrusted to the Home guards.
Partnership with private sector has been engaged in. There exists provision for
reimbursement of expenditure on medical treatment to government employees if
they undergo treatment in prescribed private hospitals in and outside the State.
Also, provision exists for engaging services of private specialists on fixed fee per case
basis, if specialist for that discipline is not available.
Functional integration of ISM&H practitioners with an aim to improve coverage
and utilization of national disease control programme and family welfare
programme. A methodology for the same has been worked out.
Limited public health functions have been entrusted to nurses, paramedics and
others after due training.
Institution specific sub-cadre of doctors has been created for institutions located in
remote areas
Staff norms for health institutions have been notified
Managerial skill upgradation of senior level officers and training of other health
personnel is underway
Service norms for health institutions have been prepared.
Civil dispensaries in rural areas re-designated as PHC1
Staff fixed according to the number of patients attending the PHCs and CHCs
Suggestions received to re-structure the cadre of Medical officers in the services of
the Directorate of Family Welfare.
Community financing introduced in hospitals through AKS
Health and family advisory committees formed at three levels of Panchayati Raj
Systems
Studies on burden of diseases by PGI Chandigarh completed
Kerala: Health sector reforms in the State focused on decentralized planning,
strengthening disease surveillance and increasing the autonomy of institutions.
d The State has initiated decentralized planning right from the inception of Ninth
Plan.
d Kerala has handed over all the health care institutions up to the district level along
with the funds to the Panchayati Raj Institutions.
d The state is implementing a district hospital project with Additional Central
Assistance from Planning Commission.
d It is proposed to provide inpatient services in General ward, pay ward and pay
rooms. A system of cross subsidy for inpatients has been proposed.
d Attempts are being made to work out the cost of care for common ailments so that
the norms for cost of care are available.
'll
Draft: Not to be cited
d
d
d
For effective vector control, the Kerala Government has initiated a "monitoring and
management of mosquitoes programme" with community participation.
Kerala is implementing a model of disease surveillance using data generated from
government and private sector health care providers.
Kerala is proposing creation of a cadre system of specialists to fill the existing
vacancies.
°
Madhya Pradesh: Madhya Pradesh has embarked on health system reforms to achieve
structural and functional improvement in government health care institutions.
d The devolution of powers both financial and administrative to the Panchayats has
been completed.
d Kogi Kalyan Samitis in all districts and a Medical Facilities Development Board at
State Level has been established
d Efforts are being made to fully operationally decentralized area specific micro
planning.
d The state is implementing Swasthya Jeevan Sewa Guarantee Yojana wherein a core
set of services are guaranteed by the State Government within a specified time frame
at the village level.
jVCT of Delhi: Delhi has taken several steps to improve health status of under-served
urban slum population through improved access to health care facilities.
d Specific efforts have been made to provide linked primary, secondary and tertiary
health care in under-served East Delhi areas through healthy city initiative.
d The Delhi government has brought out a directory of all public funded hospitals/
dispensaries in each of its constituencies as the first step of area specific
rationalization.
d In newer hospitals privatization of non medical services e.g. security, cleaning etc.
has been undertaken.
d Initiative to improve availability of essential drugs at affordable cost and rational
use of drugs has been taken up.
d Registration of all physicians in Delhi under Delhi Medical Council has been
completed.
d Hospital infection control and waste management is taken up as a major thrust area
in all tertiary, secondary and primary care institutions.
d Child friendly city action plan for 1998-2002 has been formulated and is being
implemented.
Orissa; In order to rapidly improve health care services, the State has obtained
substantial funds through externally assisted projects for strengthening primary,
secondary care infrastructure and implementation of disease control programmes. Some
of the major reforms initiated by the state are:
d Improvement in Drug Procurement and distribution in all public health institutions
through establishment of a centralized Drug Procurement and distribution system.
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User Charges were introduced to raise resources for all tertiary, and district level
government hospitals in the State for three categories of service, viz. diagnostics,
special accommodation (pay wards) and transportation.
d A pilot project initiated where the cleaning work of the State's Capital Hospital
Bhubaneswar was contracted out to Sulabh International at a negotiated price.
d Petty maintenance of health buildings: 100 CHCs/Block PHCs were identified in
the first year and each Medical Officer in charge was given Rs. 10000 to take up petty
repairs and to maintain simple accounts.
d Mandatory pre-PG rural service was introduced to improve the presence of doctors
in remote and difficult areas and provide better rural orientation to young doctors.
d Pancha Byadhi Chikitsa (5 Diseases Treatment Scheme) The scheme created health
entitlement and risk protection guarantee for the poor free of cost.
d State Health and Family Welfare Society was established to create a simple,
problem free method for making funds available under the centrally sponsored
schemes, as and when required.
d Amalgamation of District Health Societies was done to ensure better co-ordination
of all health and family welfare programmes and to avoid duplication.
d Formation of District Cadres for Paramedics
d To utilize existing health personnel for different activities the state is
implementing a scheme of multi-skilling of health personnel; under this scheme
a A pilot programme of providing a 3 month training in Anaesthesia administration
to CHC doctors to enable them to administer anaesthesia in emergency obstetric care
was taken
d Pilot project of handing over PHCs to NGOs was tried in 2 districts.
d
Rajasthan: In an attempt to improve access to health care the state has been investing
over 50% of the plan funds for primary health care for the last decade. In order to ensure
sufficient funds for development of secondary and tertiary levels of care, the State
Government has attempted the following:
a Increased Public/Private participation
a In 1995-96, the State Govt, created autonomous Medicare Relief Societies, one in
each tertiary and secondary level hospital;
d Medicare societies have promoted the adoption of wards through institutions like
Lions club. Rotary club, charitable trusts and individuals.
d Life Line Fluid Stores have been established which sell drugs and other
consumables on cost basis with a margin levied as service charges.
d Privatization of non clinical services like cleaning, laundry, security,
transportation services has been attempted in some hospitals.
a The State has allowed private sector to provide medical education and training.
a The State has attempted sharing of public sector facilities by private sector.
Tamil Nadu: Tamil Nadu embarked on health system reforms aimed at improving
antenatal care and institutional deliveries. To tackle the increasing disease burden due to
79
Draft: Not to be cited
non communicable diseases attempts were made to improve access to services aimed at
early detection and treatment of non-communicable diseases.
d Strengthening and reorganization of primary health care services was taken up
under the DANIDA assisted Area Health Care Project. PHCs were strengthened so
that facilities for emergency care and delivery are available round the clock.
d Contracting out of services in area of diet and catering, laundry, security and IEC
d Loans to purchase mopeds were provided to the ANMs to improve their mobility
so that they could visit all the villages on schedule and undertake screening of all
pregnant women and children.
d In order to improve access to facilities for early diagnosis and effective treatment of
non-communicable diseases the state had initiated a system in which a team of
specialists visit villages on a fixed schedule; after initial screening, persons detected
to have problems were referred to appropriate facilities for treatment.
d Tamil Nadu Government set up a Medical Supplies Corporation in 1994.
d Involving the industry in improving the performance of PHCs by adopting a local
PHC, health sub-centre or district hospital.
Tripura: Health reforms underway in Tripura include:
d Levying of charges in hospitals
d Establishment of pay clinics or pay cabins.
d Granting of autonomy to hospitals
d Hospital development committee has been formed.
d Services relating to maintenance of hospital has been contracted out to Sulabh
International
d Issues relating to merger, restructuring and relocation of hospitals, dispensaries and
block level PHCs is under consideration
d Limited public health functions have been entrusted to the MPWs
d Panchayati Raj Institutions have been involved in implementing health
programmes (E.g. ICDS, immunization, spraying of DDT). A three tier system of
PRI, TTAADC, Municipal Council, NGOs is involved in implementing programme
and conducting IEC activities.
d Super-speciality services at a hospital have been entrusted to a society formed with
representatives of Care Foundation Hyderabad and officials of the State
Government.
d Upgradation and expansion of select institutions / hospitals, construction of new
facilities is underway project basis, with financial assistance of different donor
agencies and the Central Government.
d A committee has been constituted to determine manpower requirements in health
institutions.
To sum, it is obvious that the Centre and the States have made every effort to implement
the recommendations of the Ninth Plan regarding health system reforms. The progress,
however, has been uneven. None of the states have implemented a comprehensive
80
Draft: Not to be cited
package of structural and functional reforms. Most have taken up essential components
of reforms such as logistics of drug supply, hospital infection control and waste
management. The coverage as well as progress varies between states. Some States have
moved far ahead in some aspects, e.g. Kerala in decentralized planning and devolution
of funds and responsibilities to PRIs while others have encountered difficulties in
implementing similar reforms. It is essential to assess progress and problems in
implementation of the reforms in each state and appropriately modify the content and
pace of implementation. In some states in the initial phases there may be greater
enthusiasm in implementation of the reforms with the centre, state and the externally
assisted programme providing financial assistance; the progress in such states should be
carefully monitored so that there is no faltering after the initial phase. Others who may
have encountered problems in the implementation of the reforms in the initial phases
have to be encouraged to persist.
Health Sector Reform: Emerging Issues
The health sector in India is at cross-roads today. On one hand, India has built up a vast
health infrastructure and manpower at primary, secondary and tertiary care in
government, voluntary and private sectors. The population has become aware of the
benefits of health related technologies for prevention, early diagnosis and effective
treatment for a wide variety of diseases and accessed available services. Technological
advances and improvement in access to health care technologies, has resulted in
substantial improvement in health indices of the population and a steep decline in
mortality. Yet at the same time, we continue to grapple with newer challenges with the
country now being in the midst of a dual disease burden of communicable and noncommunicable diseases. It is acknowledged that the existing public health infrastructure
is far from satisfactory and that the public health system suffers from paucity of funds,
lack of adequate manpower, non-availability of consumables, obsolete equipment and
dilapidated infrastructure. In spite of this, the Government has taken several steps for
improving the public health care institutions and strengthening the primary health care
infrastructure. However, the situation is compounded by severe resource constraints financial, technical and human power related, which has led to policy makers as well as
programme managers at differing levels being faced with difficult choices. In such a
situation, attempts are being made through various reform initiatives to ensure meet the
health needs of the people. Health sector reforms are underway or are being proposed in
different States across India. In fact innovative experiments are also being done across
the States with varying degrees of success. While various bi-lateral and multi-lateral
agencies (like World Bank, DFID, Health & Family Welfare Programme of EC, CIDA
amongst others) are supporting various reform initiatives or have undertaken
evaluations and / or reviews of health sector reform in India, there is insufficient and
inadequate systematic documentation and analysis of the various aspects of reform.
Such an overview and analysis of all related issues is necessary to provide evidence to
policy makers and other stakeholders in terms of the various dimensions and impact of
health sector reform. Such an analysis would be useful in suggesting the preferred
81
Draft: Not to be cited
further activities under health sector reform in India. Recognizing the need for evidence
based information about and assessment of various initiatives undertaken as part of the
health sector reform process in India, the Ministry of Health & Family Welfare,
Government of India has undertaken a review and documentation of health sector
reform initiatives in India.
In spite of being engaged in the reform process for over a decade, certain concerns and
challenges face the Indian health sector and the stakeholders especially the policy
makers. An attempt is being made to enumerate some of the areas of concerns. At the
outset there is a need to operationalize the concept of health sector reforms in the Indian
context and formulate a working definition, a broad conceptual framework that would
guide further actions. It is important to distinguish purposeful health reform from
changes in the health sector that are imposed by reforms from outside the sector as well
as from normal evolutionary and incremental system changes in the health sector. This
in turn may necessitate re-examining what has been the nature of 'health sector reform'
so far.
The nature and direction of health sector reforms are specific to each State, with each
one being situated at a different juncture in the reform process. Inspite of such
divergence, common themes and approaches, objectives and issues can be identified
across states. There is a need for policy makers at the State and Central level to exchange
experiences and information on health systems reform, sound warnings, disseminate
successes and failures, to draw lessons from and draw on best practices from
experiences of States and for all of us to gain a better understanding of the concept of
health sector reforms in India and determine the next steps to be taken. This assumes
particular significance in light of the changing role for the government in the health
sector today. The present workshop is a first step in this direction and aims to develop a
working concept of health sector reforms in India and to enable experience sharing
amongst the different stakeholders involved in the health sector reform process.
There is also a need to identify the content and process of health sector reforms
including best and doable initiatives, understand the key stakeholders involved in the
reform process and their interests in reforming the health systems, and identify areas
where gaps exist in knowledge and / or implementation of reforms, mechanisms for
continued monitoring and evaluation during implementation. Ensuring successful
implementation of reforms would require building capacities of individuals as well as
institutions within the health system at each stage in the health sector reform process. A
related issue that would require to be addressed is that of promoting research on health
sector reform. Researchable areas need to be identified and mechanisms need to build to
ensure effective linkages between research and policy making. Health policy and
systems research should be an integral art of reform agenda. Currently, there exists no
systematic mechanism at the policy level to track the impact or consequences of health
sector reform. With more information being available about the dynamics and impacts
82
Draft: Not to be cited
of specific reforms, policymakers and programme managers can make appropriate
corrections or move forward in successful directions. This in turn would require
developing an integrated system of surveillance. National Health Accounts, health
statistics and assessing health system performance. One would need to develop relevant
and accurate indicators or pointers that can be used for evaluation, for setting priorities
and for guiding programmes at national, regional and local levels. This is a collective
activity involving the key stakeholders in the health sector reform process. The
information available needs to be widely disseminated and discussed by establishing
mechanisms for shared learning and exchange of experiences and trainings. Sustained
information and education on health sector reforms is needed to generate wider political
and public understanding and support for the reform process. Towards this end,
regional resource institutions and persons need to be identified and / or inter-sectoral
groups involving the key stakeholders need to be established to support health sector
reform.
There is no one answer as to what would be the best health sector reform option. If
equity in access to basic health care must remain the goal, then the State cannot abdicate
its responsibility in the social sectors. India would have to continue with a mixed model
of government and private health care and evolve an optimal balance; the need to
strengthen the state-sector would continue and at the same time it would be necessary to
plan for a regulated growth and involvement of the private health sector as well. At the
present juncture it is pertinent that we review the impact of current options and
thereafter assess whether they could be could be implemented differently from the past
as well as if required consider introducing substantive changes in different health sector
entities and functions. Any options we agree upon need to build in flexibility to deal
with the differing realities across States. The way ahead should be based on
consultations, debates and by forging a consensus amongst policy makers at Centre and
State and other stakeholders and should aim towards increasing equity, efficiency
effectiveness and thereby, meeting the health needs of the population.
References
Bajpai Nirupam (2002), A Decade of Economic Reforms in India: the Unfinished
Agenda, CID Working Paper No. 89: Center for International Development, Harvard
University
Berman Peter & Bossert Thomas (2000) A Decade of Health Sector Reform in Developing
Countries: What Have We Learned?, Data for Decision Making Project, Harvard School
of Public Health, A paper prepared for the DDM Symposium: "Appraising a Decade of
Health Sector Reform in Developing Countries " March 15, Washington, D.C.
83
Draft: Not to be cited
Berman, Peter (1995), Health Sector Reform: Making Health Development Sustainable In
Peter Berman, ed. Health Sector Reform in Developing Countries: Making Health Development
Sustainable. Boston: Harvard University Press
Figueras Josep, Saltman Richard & Mossialos Elias (1997), 'Challenges in Evaluating
Health Sector Reform: An Overview, LSE Health, Discussion Paper No. 8
Gilson Lucy & Mills Anne (1995), Health Sector Reforms in Sub-Saharan Africa: Lessons
of the Last 10 Years, In Peter Berman, ed. Health Sector Reform in Developing Countries:
Making Health Development Sustainable. Boston: Harvard University Press
Government of India, 'Economic Reforms: A Medium Term
Recommendations of Prime Minister's Economic Advisory Council, 2001
Perspective;
Government of India, Eighth Five Year Plan, (1992-1997) Planning Commission, New
Delhi
Government of India, Ninth Five Year Plan, ( 1997- 2002) Planning Commission, New
Delhi
Government of India, Tenth Five Year Plan (2002-2007) Planning Commission, New
Delhi
Implications on Health Sector Reform on Reproductive Health Rights. (1998) Report of a
Meeting of the Working Group for Reproductive Health and Family Planning,
Washington: Center for Health and Gender Equity. The Population Council.
Johnson Sarah (2000), Building capacity in Human Resources Management for Health
Sector Reform and the Organizations and Institutions comprising the sector, LAC Health
Sector Reform Initiative
Mills Anne, Bennett Sara, Russell Steven with others, (2001) The Challenge of Health
Sector Reforms: What must governments do?, Palgrave
Planning Commission, Annual Report (2001-02), Govt, of India, New Delhi
Planning Commission, Annual Report (2002-03), Govt, of India, New Delhi
Standing Hilary (2002),' An Overview of Changing Agendas in Health Sector Reforms',
Reproductive Health Matters, Vol. 10, No 20, pp. 19 - 28, Elsevier Science.
84
Draft: Not to be cited
Thomason Jane A, 'Health Sector Reform in Developing Countries: A Reality Check':
Assessed at http://www.sph.uq.edu.au/acithn/conf97/papers97/thomason.htm Site last
assessed on June 25, 2003.
World Development Report, Investing in Health (1993), World Bank
World Health Organization (1997), 'Health Sector Reform: Report & Documentation of
the Technical Discussions, 54th Session of the WHO Regional Committee for South East
Asia, Thimpu, Bhutan, 8-12 September, 1997': WHO Regional Office for South East
Asia: New Delhi.
World Health Organization (2000) Health sector reform: Issues and Opportunities, 18th
Meeting of Ministers of Health, Kathmandu, Nepal, August 2000.
World Health Organization (2002), 'Health Situation in the South East Asian Region
1998-2000', Regional Office for South East Asia, New Delhi, pp. 189
85
Power Point Presentations
I
List of Power Point Presentations
1. India’s Health System: Role of Health Sector Reforms
2. An Overview of Health Sector Reforms
3. Health Sector Reforms in Punjab
4. Rajasthan Health Sector Reform: A Perspective
5. Reforms in Health Services in Gujarat
6. Health System Reforms in Himachal Pradesh
7. Health Sector Reforms in Uttaranchal
8. From First Phase to Second Phase of RCH
9. Synopsis of Day 1
Dr. Prema Ramachandran
Dr. Rama Baru
Ms. Anjali Bhawra
Dr. B Sekhar,
Shri S. K. Nanda
Dr. R. N. Mahanta
Dr. I.S. Pal
Ms. Nandita Chatterjee
Ms. Anagha Khot
Health system Consists of
INDIA’S HEALTH SYSTEM - ROLE OF
HEALTH SYSTEMS REFORMS
Prema Ramachandran
Adviser(Health) Planning Commission
>Primary, secondary and tertiary care institutions,
manned by medical and paramedical personnel to
provide health services
>Medical colleges and paraprofessional training
institutions to train the needed manpower and give the
required academic input
> Programme
managers
managing
ongoing
programmes at central, state and district levels
>HMIS - two way system of data collection, collation,
analysis and response.
They are not linked appropriately and do
not function as cohesive parts of the system
bwl.
A't**
100
90
•
0
60
L
so
1 40
"I
.-•i
I
r -'
ji
111
■J'
:
I I
30,
20
)0-
n] u I- • jI j i | ! I f
<20%
2(^9 9% ■4^9.9%
Paradoxes in health sector
0j o
■Il
i
Current problems in providing health care
>Persistent gaps/ mismatch
in manpower &
infrastructure especially in primary health care in
areas where health care needs are greatest,
>Plethora of hospitals in Govt., voluntary and
private sector not having appropriate manpower,
diagnostic and therapeutic services and drugs,
>Sub-optimal functioning of the infrastructure;
poor referral services,
> Availability and utilisation of services are
poorest in the most needy remote rural areas in
states/districts.
>Massive interstate/ inter district / urban rural
differences in nerformance
>Plethora of hospitals but few located in areas with
high morbidity.
>Huge health manpower - many underemployed
some unemployed - still unqualified persons practice
>Vast sums spent on drugs and diagnostics- unused
piles of drugs in some places & lack of appropriate
diagnostics and drugs in others
>Lack of defined norms for of care at each level &
referral
>Primary care workers not given the responsibility
of gate keepers; their referrals are not honoured.
>Some hospitals overcrowded; many underutilised
HEALTH CARE INSTITUTIONS
>Good facilities with skilled staff;
But they face
>Difficulty in running institutions because of
■Changing health care needs
■Rapid advances in technology
■Obsolescence of equipment
■Rapid turn over of staff
>Conflicting imperatives of
■Having to contain costs & be self sustaining
■Shouldering social responsibility
■Dealing with labour & consumer litigations
e
ST
Public and private sector shares in service Delivery lor those Above and
Below Poverty I . inc. All India. 1995-96
HEALTH PERSONNEL
loo
>HighIy skilled, competent and committed
xo
But Require
>CME providing up dated information on
■ rational use of drugs and
■ protocols for management of illnesses
>System of screening and referral
>Access to institutions with adequate staff
>QuaIity control systems which ensure that
■ patients get appropriate care
■Cost of care is not prohibitive
■ physicians get protection against litigation
Public Sector
APL
80
60
40
I
74
r IB
56
BPI
Antenatal
carc
API
I
fB:
““ ■
BPI
API
llospitalizuiion
API.
BPI
< iutpulicnl
0 i._L
Ci
n 158 154 140 j
ns
2<
i:
4(
fts?
-] *
■ B1
„
n’
^2‘
i:
20
OP
IP
SOURCE . NATIONAL SAMPLE SURVEY. 42nd & 52nd ROUND
BPI
lnsiiiution.il
Insiilutional
deliveries
Averag; Hospital Charge per inpatient day by public and
private
350 297 - '■
' f. ’ \
300- r 269 25r
203
201.
40
0
Private Sector
Souicc NCAI-.K-Wliii Bcni lii-. Iriim PuIiIil Ikalili Spending in India and
NSS< >,
.X
199^-96
100
API.
BPI
I nun tin isulion
SHARE OF PRIVATE SECTOR OF OUTPATIENT &
INPA HF^TCARE
B.i -
B2
;
i
PUBLIC
.....
<'» ■ 1
opr,vate
Source Mahal el ats Who Benefits from Public Health pending in India,
NCAER 2000
8^
i
1
I
Out - of Pocket Payments and I louse hold Income1995-96
600
Sources of Financing for Private Expenditures
on«1S8non^
500
I sS Public Facilities ®E Private Facilities^
400
■ jzhImmc
. 60W»0% .
300
. . ...
3
]
..zk
i
2“.
200
100
0
...
a
k
s
I
1
/
z
Source NCAER-Who Benefits from Public Health Spending in
India and NSSO. 1995-96
. .
0
10
Borrowed
20
30
; ........... .
j .|
40
70
50
percent
Sold assets
60
I
80
,1
I
90
100
■- Used
- ----------savings
NCAER-Who Benefits
, . from
..., Public Health
lg in India and
NSSO, 1995-96
Spending
wdNSSO...
... .xr-v,
THE PEOPLE
>Responsible, rational, increasingly aware
>SIow to respond but response is sustained
>Willing to invest for and in health Edit
^Diagnosis and management of illnesses are
becoming increasingly complex and costly ;
^Trusted family physicians have vanished
>With commercialisation of health care fear
■Potential for poor quality care
■Problems due for overuse, abuse and
misuse of technology &
■Exploitation of vulnerable patients
Health sector -Emerging problems
>Dual disease burden of communicable and
non-communicable diseases
>Technological advances which widen the
spectrum of possible interventions,
>Increasing awareness and expectations of
the population regarding health care services,
>Escalating costs of health care and ever
widening gaps between what is possible and
what the individual, institution or the country
Can afford.
Ninth Plan emphasized the need to :
>Review the response of the public, voluntary
and private sector health care providers as well as
the population themselves to the changing health
scenario
> Reorganise and restructure health services so
that they they function as integral components of
an efficeint and effective multiprofessional health
system
> Introduce health system reforms to enable the
population to obtain optimum care at affordable
cost.
Health system reforms broadly fall into
three categories:
^structural and functional aimed at
improving efficiency,
^financial aimed at improving the
resources available and
^governance related aimed at
improving transparency/ accountability.
It was envisaged that the public sector
would play the lead role in health
systems reform
Who are the stakeholders
States - as Health is a state subject
Centre -as
effective implementation of the
CSS requires an efficient state health care
infrastructure.
Health care Institutions - as they
can
function better according to defined norms
Health care providers- as they will get
essential requirements to provide care
People - because they need access to good
quality care health at affordable cost
Structural Reforms
teorganisation and restructuring of existing health
e infrastructure including the infrastructure for
ivering ISM&H services at primary, secondary and
tiary care levels, so that they have the responsibility
serving population residing in a well defined area
1 have appropriate referral linkages with each
er.
lainstreaming of the ISM&H manpower and
rastructure to improve access to health care
1 performance under the national disease
itrol programmes and Family Welfare
(gramme
‘to
Human resource development
>Human resource development to meet
growing/changing health care needs adequate in number, with appropriate
skills & attitudes.
(l;
>Skill up gradation of health care
providers through CME; redeployment
of the existing health manpower so that
they can take care of the existing and
emerging health problems at primary,
secondary and tertiary care levels.
>Horizontal integration of current vertical
programmes and
ongoing state sector
programmes at& below district level;
>Integrated
system
for district based
administration, planning, implementation,
monitoring, IEC, training, supplies
> Building up efficient and effective logistic
system for supply of drug, vaccines and,
consumables based on the need and
utilisation
Functional reforms
Governance Related
>Fully functional accurate reporting system which
provides data on births, deaths, diseases and data
pertaining to ongoing programme through service
channels, within existing infrastructure;
monitoring and evaluation of these reports and
appropriate midcourse corrections to be done at
district level;
> Building up an effective system of disease
surveillance and response at district, state and
national level within and as a part of existing health
services
>Introduce a range of comprehensive regulations
prescribing minimum requirements of qualified
staff, conditions for carrying out specialized
interventions and a set of established procedures
for quality assurance.
>Evolving standard protocols for care for various
illnesses at primary, secondary & tertiary care
with the help from public sector hospitals,
medical colleges, professional associations
> Working out cost of diagnostics and therapeutic
procedures for major/ minor ailments in different
levels of care and setting cost of care norms.
Functional reforms
Quality of Care
Quality Control system in India will:
^Assessment of quality of care is
not a value judgement.
&
J Quantifiable
determinants
ingredients of quality include::
> Infrastructure/manpower
> Processes for diagnosis
and
treatment,
>Intervention - Safety & timeliness
>Outcome - case fatality, disability
>Cost of care
♦♦♦Prevent over use, under use, abuse, misuse <
facilities
♦♦♦Improve effectiveness and efficiency
❖Help to make positive outcomes more likely
❖Help to
use of resources effectively an
responsibly
❖Minimise barriers to appropriate care ;
different levels by matching levels of care to lev
of need;bring in accountability in the heall
system
❖Open the gates for Health tourism
Governance Related
> Appropriate delegation of powers to Panchayati
Raj Institutions (PRIs) so that the problems of
absenteeism and poor performance can be sorted
out locally and primary health care personnel
function as an effective team.
>Involvement of the Panchayati Raj Institutions in
the planning and monitoring ongoing programmes
and taking timely corrections for optimal
utilisation of services.
>Better access to information what types of
services are available where and at what cost
Financial Reforms
>Continued commitment to provide essential primary
health care, emergency life saving services, services under
the National Disease Control Programmes and the
National Family Welfare Programme totally free of cost to
individuals based on their needs & not on ability to pay
>Evolve, test and implement suitable strategies for levying
user charges for health care services from people above
poverty line, while providing free service to people below
poverty line; utilise the collected funds locally to improve
quality of care.
>EvoIve and implement a mechanism to ensure
sustainability of ongoing govt, funded health and family
welfare programmes especially those with substantial
external assistance.
!
AN OVERVIEW OF HEALTH
SECTOR REFORMS
' • This presentation provides an overviev/ of
i
the following:
; • The Political and Economic context of
i
health sector reforms (HSR)
• The elements included under HSR
• Donor Funding and HSR
; • International experience with HSR
i • HSR in India
Context of HSRs -2
• Since the emphasis was to reduce state
involvement, methodologies were
developed for both assessing and
prioritising investments in health were
driven by the objective of cost
effectiveness.
• Many of these strategies included
contracting out, introduction of user charges
in public facilities, incentives and subsidies
for private sector etc
Context of HSR
• The world recession of the late seventies and early
eighties is the context within which HSRs
emerged
• The motivation for HSRs was to reduce
government spending and increase the role for
markets
• Public provisioning was seen as inefficient as
compared to markets that were characterised as
efficient and more responsive to the needs of
‘consumers’
• As a result there was a shift away from the welfare
slate to greater reliance on markets
Definition and Elements of HSR
• An accepted definition of HSR includes:
• improving the civil service
• decentralisation of power and resources
• improving function of health ministries
• broadening health financing
• increasing the role of private sector in the
financing of provisioning of health care
■^3
Elements of HSR
• Elements that have been included as a part of HSR
are:
• Privatisation of health services specially at secondary
and tertiary levels of care
• Introduction of cost recovery mechanisms that were
seen to enhance cost effectiveness and also improve
quality of services. These include introduction of user
fees; contracting out of ancillary services in public
sector
• Implemention of “essential services “for specified
target groups at the primary level.
• Decentralisation of services- financial and
administrative
Donor Funding and HSRs
• HSRs were seen as a response to fiscal
constraints that were being faced in both
developed countries
• They were driven by an ideological position
that placed greater faith in the market than
the state
• The elements of HSR were globalised
through both multilateral and bilateral
agencies
Donors and HSR
• One of the motivations for donor funding for
HSRs was to ‘cushion the impact of globalisation’
• It was also seen as a way of ‘rationalising costs’ in
the health sector
• Uptil the 1980s the donor funding for the health
sector was dominated by bilaterals
• The 1990s witnessed the emergence of the World
Bank as the single largest agency to fund the
health sector in the developing world.
• Loans were given by the World Bank to the health
sector as a part of the Structural Adjustment
Programme
Donors and HSR
• The loans to the health sector were tied with
conditionalities in terms of defining the
programme content, choice of technology,
programme priorties
• The loans were earmarked for specific
programmes like disease control.
Reproductive and Child Health, primary
health care and restructuring of secondary
and tertiary levels of services
Experience of HSR
HSR in India
• Much of the evidence pertains to the African and Asian
countries with respect to HSR
• The various studies show that elements like privatisation,
user charges have reduced access, especially for the poor
and sections of the middle classes.
• Privatisation and corporatisation of health services has
increased costs.
• It has also affected the quality of public provisioning
• User charges in the public sector are not an important
source of revenue, as was believed.
• A recent review of experiences with contracting out shows
that the administrative costs to manage it has proven to be
not cost effective.
• The market failures in health services is now well accepted
• A few elements of HSR like privatisation started during
the late 1970’s and early ‘80s
• 1991-India opts for SAPs in the economic domain
• Loans from the World Bank with support from bilateral
agencies to the health sector begin by the mid 1990s. The
Indian government opts for these loans to deal with the
fiscal crisis in the health sector specially at the state level
• These loans were given to specific projects that included
disease control programmes, Reproductive and Child
Health programmes, primary level care and the state health
systems projects- that dealt with secondary and tertiary
levels of provisioning
HSRs in India-2
•
•
•
•
Each of these projects had specific conditionalities regarding tie use
of loans
For example- the disease control programmes gave priority to a few
diseases and also specified the kind of technology to be used. In the
case of the health systems projects the items for which the loans
were to be used were specified It also called for introduction of
user fees and contracting out in public hospitals
Although these loans were negotiated between the Bank and the
respective states. The spaces for negotiation were small given the
unequal relationship that exists between the lender and the boirower
The spaces for negotiation were small given the unequal relationship
that exists between the lender and the borrower
HSR in India-3
• A few studies on the reform of secondary and tertiary
levels as a part of the health systems project in states like
Andhra Pradesh raise a number of important questions.
• The health systems project was initiated during the mid
1990s across several states and a major percentage of the
loans was spent on civil works, equipment and drugs.
• Investments in these areas was seen as necessary to
enhance patient supply. Through the introduction of user
fees it was assumed that additional revenues could be
generated.
■7s
HSRs in India-4
• Studies from Andhra Pradesh show that even after these
investments the out patient and inpatient numbers did r ot
increase significantly. The middle classes who had moved
out of public sector to the private sector during the mid
eighties did not start utilising the public sector.
• User fees that were introduced met with resistance and met
with protests in Andhra Pradesh. However they have been
reintroduced despite the protests.
• Since the fiscal crisis continues the financial sustainability
of these projects is of concern
• There is a need to document and share the process and
experience of HSRs across states and this workshop is an
important contribution to this area.
NEED FOR HEALTH SECTOR REFORMS
QUALITY OF HEALTH CARE DELIVERY.
WORKSHOP
COST OF ITS DELIVERY.
ON
INCREASING HEALTH EXPENDITURE.
INDIA’S HEALTH SYSTEM : ROLE OF HEALTH
SECTOR REFORMS
RESOURCES ALLOCATION DILEMMA.
THE PROBLEM IS COMPOUNDED DUE TO
SEPTEMBER 4-5, 2003
LACK OF PATIENT SATISFACTION
HETEROGENITY
INTANGIBLE OUTPUT
MS. ANJALI BH/kWRA.IAS
MANAGING DIRECTOR-PHSC
& SPECIAL SECRETARY HEALTH. PUNJAB
INITIATIVES TAKEN BY THE GOVERNMENT
OF PUNJAB
PROCESS INITIATION
RE-EVALUATION OF THE HEALTH NEEDS OF THE
COMMUNITY.
IMPLEMENTATION OF USER CHARGES
ASSESSEMENT OF THE DEPLOYABLE RESOURCES
IN HEALTH SECTOR.
RETENTION & UTILIZATION OF USER CHARGES
AT THE POINT OF COLLECTION
ANALYSIS AND REPRIORITIZATION
NEEDS AND RESOURCES.
OF
THE
LINKING ADDITIONAL RESOURCES TO IMPROVE
HEALTH CARE DELIVERY
HIGHER FINANCIAL POWERS TO BRING
AUTONOMY
MEDICAL INSURANCE SCHEME.
DEMOCRATIC DECENTRALIZATION
OUTSOURCING OF SERVICES
MORE
I
INITIATIVES TAKEN BY THE GOVERNMENT
OF PUNJAB
PUBLIC - PRIVATE MIX
REVAMPING
SERVICES
OF
HEALTH CARE
MOBILITY
PRIMARY
DELIVERY
HEALTH
THROUGH
EMPHASIS ON MAINTENANCE OF
OPTIMUM UTILIZATION
CARE
BETTER
ASSETS
&
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
IMPLEMENTATION OF USER CHARGES
IMPLEMENTATION OF USER CHARGES POLICY
SPECIFICALLY IN THE SECONDARY LEVEL
HEALTH CARE SERVICES.
COLLECTIONS
RIGOROUS.
PROCEDURES
MADE
MORE
RATIONALIZATION OF USER CHARGES.
INDEXING USER CHARGES IN ORDER TO COVER
OPERATIONAL
EXPENSES
EXCLUDING
MANPOWER COST AND CAPITAL COST.
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
LINKING ADDITIONAL RESOURCES TO IMPROVE HEALTH
CARE DELIVERY
HIGHER FINANCIAL POWERS TO BRING MORE
AUTONOMY:
ADOPTING THE POLICY FOR
UTILIZATION OF USER CHARGES
RETENTION
SETTING OUT PRIORITIES FOR UTILIZATION:
- DRUGS 45%
- IMPROVING FACILITY FO THE PATIENTS (25%)
- MAINTENANCE OF BUILDING (15%)
- MAINTENANCE OF EQUIPMENT (15%)
&
MEETING DAY-TO-DAY EMERGENY REQU I RE
MENTS FOR DRUGS, REPAIR OF IHOSPITAL
EQUIPMENT & OTHER CONTINGENCIES.
CUTTING DOWN / BREAK
DIAGNOSTIC / EQUIPMENT.
DOWN
TIME
OF
SENSE OF BELONGINGNESS.
MANAGEMENT OF EMERGENCIES.
DELEGATION
WILL
ACCOUNTABILITY.
BRING
MORE
‘fg
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
IMPLEMENTATION OF MEDICAL INSURANCE SCHEME;
DEMOCRATIC DECENTRALJZATION:
GOVERNMENT IS IN PROCESS OF HIRING A
CONSULTANCY FOR DEVELOPING A SCHEME TO
ADDRESS THE UNMET NEED OF GOVERNMENT
EMPLOYEES, PENSIONERS, AND PEOPLE BELOW
POVERTY LINE.
GOVERNMENT HAS PREPARED A SCHEDULE OF
THE
FINANCIAL
POWERS
AND
THE
ADMINISTRATIVE POWERS TO BE TRANSFERRED
TO P.R.IS. ALONG WITH THE TIME FRAME.
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
OUTSOURCING OF SERVICES:
COMPLETED
SELECTED CLINICAL SERVICES.
SECURITY SERVICES
SANITATION SERVICES.
AMBULANCE SERVICES.
PIPELINE
DIAGNOSTIC SERVICES.
MEDICAL WASTE DISPOSABLE SERVICES.
CASH COLLECTION SERVICES.
COMPUTERIZATION SERVICES.
MAINTENANCE SERVICES.
THE SCHEDULE HAS BEEN COMMUNICATED TO
D.R.D.P. FOR CONFIRMATION.
MJBL!C_-.P!«yATE_MIX:
STATE GOVERNMENT IS INITIATING A PROJECT
WITH THE HELP OF PUNJAB INFRASTRUCTURE
DEVELOPMENT BOARD FOR HANDING OVER O&M
OF SELECTED HOSPITALS IN THE STATE.
ONE PROPOSAL FOR 150 BEDDED HOSPITAL AT
AMRITSAR IS AT ADVANCED STAGE.
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
REVAMPINIG OF PRIMARY HEALTH CARE SERVICES:
HEALTH CARE DELIVERY THROUGH BETTER MOBILITY:
PROCESS INITIATED FOR HIRING A CONSULTANT.
INTRODUCTION OF MOBILE HEALTH CLINICS.
ASSESS & EVALUATE THE CURRENT STRUCTURE
OF PRIMARY HEALTH CARE SYSTEM.
STRENGTHENING OF PRIMARY & SECONDARY
HEALTH INSTITUTIONS.
UNDERLINE
THE
AREAS
REQUIRING
STRENGTHENING AND RESTRUCTURING.
PROPOSAL FOR INTEGRATION OF OTHER SYTEM
OF MEDICINE AND BRINGING THEM UNDER ONE
ROOF FOR COST EFFECTIVE PURPOSES.
IDENTIFICATION OF CRITICAL NEEDS & GAPS.
EVOLVING
AN
INTEGRATED
SURVEILLANCE SYSTEM.
DISEASE
INITIATIVES TAKEN BY THE GOVERNMENT OF PUNJAB
EMPHASIZE ON MAINTENANCE OF ASSETS:
PRIORITIZING MAINTENANCE
CREATION OF ASSETS.
RATHER
THAN
HIGHER ALLOCATION FOR MAITENANCE BUDGET.
INTEGRATION
OF
HEALTH
MAINTENANCE
INFRASTRUCTURE INVOLVING D.R.M.E., P.H.S.C.,
D.O.H.F.W., E.S.I. DISPENSARIES, AYURVEDA, AND
HOMOEOPATHY.
INITIATIVES TAKEN BY PHSC
• BENCH MARKING
• WASTE DISPOSAL SYSTEM
• GRADING OF THE HOSPITALS
• REGULAR MONITORING
• TRAINING
loo
BUDGET ALLOCATIONS
HEALTH INFRASTRUCTURE IN PUNJAII
'.ISO
HEALTH INSTITUTIONS
DIRECTORATE OF
HEALTH (OHS)
boo -
PUNJAB HEALTH
SYSTEMS CORPORATION
________ (PHSC)________
IMO
Name of Health
institution
No.
Name of Health institution
Hospitals / Community
Health Centre (CHC)
160
District Hospital (OH)
6
Primary Health Centre
(PHC)______________
484
Sub Divisional Hospital
(SDH)________________
45
Subsidiary Health Centre
(SHC) / Dispensary
(Rurat&Urban)
1.465
Community Health Centre
116
Sub Centre
2.852
No.
C Total Budget
Non-Plan (In
Crore)
■ Expelindltura
Salary (In
Crore)
poo
134.SS
ISO
‘ 111.44
rl
1M.&3
-It
a
J
THANK YOU
lOi
pH | 2-"2^
Framework of Presentation
Rajasthan
Health Sector Reform
A Perspective
Brief introduction to Rajasthan
n. Health sector reforms- Past efforts
III. Unfinished challenges
i.
Dr B Sekhar IAS
Special Secretary, Medical and Health, Govt of Rajasthan
Workshop on Health Sector Reforms, Sept. 4-5,2003
Ministry of Health & FW
New Delhi
I. Brief Background of Rajasthan
I.Brief Background of Rajasthan
PanfcrfMx,. ...
Popuhlion (2001) n odfon
Dwidal population grotwh
W.5
1027
Mir
21.34
Sex raio (fcmak. per
922
9B
PoptMion rbnrty (peraora
pc<»qkm)
...........
165
324
Per ww urban
PwcartO-Cn.______
treaty nut tottl
23.4
18.5
61.03
Lreacyratetnefc
Ireacyntfc fcrmle
Per cert SchxMsd Cart
(1991)____________
Per CM Schedubd Tribe
(1991)_____________
76.46
44,34
27 It
114
65.il
75,85
54.16
167
17.29
12.44
Total falfcyaiB (199?)
Crude brti rate (1999)
Cwie'tiealh rtle(1999) .
Inint mortally rate (1999)
.11.1
26 I
51
70
Hospitals (CHC)
..
•jjWitoer
Divisions
'
Districts__________
Sub Divisions
Tehsils
Municipalities
Panchayal Sanities
VHAgfi Panchayat
Total Villages
Inhabited Villages
Cities/Towns
___ 6
32
188
241
183
237
9188
39810
37889
222
____
_____________
MCW Center
PHC (Upgraded PHC)
PHC (Uiban)_______
Sub Center________
F.W. Centre’_______
Beds
.
'
Doctors_____ „
Poputatton(2001)
Budyt(Laks)_______
Budyi per person (Rs.)
Population per bed
Poputationper doctor
Poputnion per institution
219,(72) 219
--- (72)
--T-"
--•r219(72)
-•••
219(72)
219- (72)
268
268
268 ___ 268
268
118 ___ 118 ___ 118 ___ liS
1674
1662
1674
1674
(646
(190^
(19})
(191)
(191)
(190)
____ 20 ____ 24 ____ 29 ___ 29 ____ 29
9926
9926
9650
9851
9926
293 __ 293
293 __ 293 ___ 293
37486 37766 37918 37918 37918
6'106
6252
6107
6143
6184
440.06 440,06 440.06 440 06 564.73
100616
102231
69346,5 86132 106871
157.58 195.73 242.85 228.64 181.02
1161
1489
1161
1174
1165
9033
7116
7207
7206
7164
4611
3593
3624
3691
3593
I0X
Background...
Background...
Distribution and (rend of Human resources nt primary and secondary level
>*et»oiinel Caicyoty
■Svnior.Spra»bl>
JuniiT Speviifclt
[Senior Mnl. Officer
CAS<DctIbI
Nuixmg SlaO'
I J.l) lk-.thVuilor
ANSI________
■Sr.LT/LT
~
[Sr. Rad •Rada.. AR
[Food Inspectors
9I./92
9?.<V3
•M/W
232
1076
947
2919
9610
1298
10148
1912
44.2
111
1116
947
.1044
9784
1.303
10298
241
1187
960
1178
1<XW
1.108
10442
2065
510
3-1
34
482
34
Stttagih (w Numlter)
■' 1 W-W
'
• W594'9?
;
239
234
231
1203
1284
1299
897
145
897
1229
3518
3554
10149
10656
HI76O
1108
1.308
IX>8
10571
11271
11991
2138
2246
2271
519
5.34
539
34
34
34
Analysis of Public Health Expenditure by Major Heads of Expenditm e
20014)2.
~ 222 "
224
234
1.325
1438
I486
8'i|
892
783
.1657
3554
3527
.1891
111942
12029
1358
1358
1158
12291 '
227!
12271
2355 ~
2326
2262
545
527
527
34
34
34
97%'
Major Heads________________________
1998/99
1999/00 2000/DI
2001/02
Total Government Expenditure on Health
Of which____________________________
4323.55
39603 8 41084 I
42382
Salaries (amount)_____________________
Salaries (share of lotal expenditme)
3474,59 32258.6 34006,2 34920.7
80,3
81.45
82,77 __82J9
186.75 1543.46
1698,8 1609,35
___ 4,3
3 89
4 13
3 79
26.05
78.49
111.43
62 36
____ 0.6 ___ 0.2
0.27
0 14
Drugs (amount)_______________________
Drugs (share of total)_________________
Maintenance of equipment amount) __
Maintenance of equipment (share)
Maintenance of Vehicles (amount)
10,42
72,02
63.44
65.14
Maintenance of vehicles (share)
0.24
0.18
0.15
0 15
Growth Rate
Background...
I’erecitogc AHieutionoflMilic lix[>etditue by I cvck
l-.\|x-it!itiji.-U-vel
i 94/5
::'
P.spcnditun: al I’rnnary I encl (including
52.6
53.8
I'W) ________________
1-A-pcitlilun.- at Secondary Ixvvl
______
23.2
lixpcalitiie at Tertiary Ixvel mxikal
23 7
23
cnDeges)
L
96/7
21.6
97«
55.7
54 16
53.73
22.6
21.7
21.97
23.S7
21 K3
24 44
Rajasthan-Diversity: Sex Ratio
II. Health Sector Reforms
Past Efforts
Financing methods
Changes in health system organization
Regulation of private sector
Re-organization and re-structuring of
existing government health care system
5. Reforms related to human resources
6. Drug policy and procurement
1.
2.
3.
4.
Public Sector Use in Rajasthan
II. Health Sector Reforms- Past
Efforts (Cont.)
7. Policy Reforms
8. Private/NGO/Voluntary and Public
Partnerships
9. Equity Enablers
lotf-
1. HSR-Financing Methods
Medicare Relief Society (MRS)
Background
MRS-Objectives
• To compliment and supplement the health
facility thorough generation of additional
revenue
• MRS created in 1995 in all hospitals with 100 or
more beds; Now expanded up-to CHC level
• In 1980 pay clinics and auto finance scheme were
tried but they were not successful
- Did not offer any incentives to generate revenue
- Revenue generated were deposited in State Treasury
• To retain and use the resources generated in
the hospital through decentralized decision
making
MRS-Functions
MRS-Management Structure
• Provide low cost diagnostic and treatment services
• Provide free medical services to poor and
disadvantaged
• Obtain donations from financial institutions
• Conserve resources through adopting wards and
opening of life line fluid stores
• Arranging facilities - Sulabh complex,
maintenance of buildings, equipment, contracting
out services
• Autonomous management committee
comprised of official and non-official
members at State, Regional and District
level
• Executive Committee to take day to day
decisions
I05
MRS-Source of Funds
• Seed money by State Government
• Transfer of operational control of diagnostic
machines to the societies
• Societies authorized to levy user charges
• Authorized to retain income from auction of
other support services
• Authorized to accept grants and donations
and loans
MRS-Use of Funds
• Maintenance and renovation of building
• Maintenance and repair of equipments
• Purchase of new equipments
• Improving sanitation and cleanliness
• Improving other facilities for patients and
attendents
• Computrisation of various system
• Free medicines for BPL
MRS-Exempted Category
• Families living below the poverty line
• Widows
• Freedom fighters
• Destitute
• Citizens over 70 years
• Retired Govt. Servant
MRS-Challenges
• Rationale Use of surplus funds
• Ensuring free services to exempted categories
• Ensuring 25 % of surplus funds for BPL
• Use of funds in same financial year
• Developing systems for setting user fee
• Expanding the scope for levying user fee
• Ensure proper systems for perspective
planning and accounting
to&
B. Life Line Fluid Stores (LLFS)
• LLFS started all hospitals with 100 or more
beds
• LV. fluids, Surgicals items and injectable
Antibiotics are provided to patients to 40 to
50 market cost
• The services are available 24 hours
• No financial involvement of the department
or M.R.S.
A. Decentralization
• District health societies
• Relocation of Dy. CMHO offices
• Delegation/ devolution to Panchayati Raj
2. Changes in Health System
Organization
A. Decentralization
B. Granting autonomy of hospitals/ CHCs/
PHCs
C. Contracting-out
D. Appointments on contract-basis
E. IEC Bureau
B. Granting Autonomy to
Institutions
• Medicare Relief Societies
lo?-
C. Contracting-out
• Cleaning services in hospitals
• Computer operators- Rs 6,000 machine +
operator
• Computerization on BOT basis
E. Information, Education and
Communication Bureau
• Established in 1990
• Comprehensive reorganization of
fragmented efforts in IEC
• Planning, monitoring of IEC techniques
• Research and experimentation
• Production of material and providing
technical support services
D. Appointments on Contract
basis
• ANMs
• Lab technicians
• Staff nurses
• Medical officers
3. Regulation of Private Sector
• The Rajasthan Clinical Establishment
Regulation Bill, 2001/ 2002 - in process
log
4. Re-organization and Re
structuring of Existing Govt.
Health Care System
• Dy. CMHO office relocation
6. Drug Policy and Procurement
• Essential drug list and directions
5. Reforms Related to Human
Resources
• Anesthetists short-fall: 3 months training
• Rational allocation of resources
• Certification
7. Policy Reforms
• Population policy & RG Population Mission
• Training policy
• Essential drug policy
• Private sector in Health policy
• Transfer policy
• Health Vision 2025
Population Policy & RG Mission
• Second State in India to formulate State
Population Policy
• Launched in January 2000
• Rajiv Gandhi Population Mission in July 2001
established for effective implementation of
the Policy and Population Programme
Policy to Promote Private Sector
• Permitting Private Sector in Medical, Dental,
Nursing and Para-clinical Education
• Allotment of land
Essential Drug Policy
• Rational use of drugs
• Essential Drug List
• Quality, Access and Availability
Policies Under Consideration
• State Health Policy
• Anti Quackery Bill
• Clinical Establishment Act
• Regulatory Authority for Health Care and
Medical Education
no
8. Private/ NGO/ Voluntary
Sector
• Jan Manga! Scheme
• Swasthya Mitra - village level worker
• Private- Medical Colleges, Nursing
Colleges and Schools
9. Equity Enablers
• BPL Medicare Card Scheme - Medicare
Relief Society
III. Unfinished Challenges
1. Organizational restructuring
2. Enhancing management capabilities
3. Addressing geographical, social, gender
inequities
4. Encouraging and regulating private sector
5. Improving quality
6. Protection from impoverishment
Thanks!!
in
Reforms in
Health Services
provided by
Gujarat State
A fundamental, sustainable,
purposeful and positive process
towards health services provision made in
two different directions
* CONTRACTING OUT
*
’*
RESOURCE ALLOCATION
• Grouping of the CHCs:
At least 4 specialists are available In selected potential CHCs by rearranging
posts of specialists
DECENTRALIZATION with RESOURCE ALLOCATION & MANAGEMENT;
• "Creation of Block Health Office”:
To assist District Health Organisation in planning. Implementation and
review of activities related to Primary Health Centres (PHC), to facilitate
supplies of medicines and vaccines and to data flow
- Establishment of Emergency Obstetric Care services in tribal and
inaccessible area:
Piloted In a taluka with training and net working for early referrals
• Application of GIS in planning of activities related to malaria
control;
Mapping of all 18000 villages for last four years for micro planning of
control activities by district and sub district officials
• Minor repair work in PHC/SC buildings
- For developing strategies and creative under IEC to bring
professionalism
• RE-ORGANIZATION OF INFRASTRUCTURE
• Cadre of Para Medical Ophthalmic Assistant according to
community needs
- 'Urban Health Care' Project proposed for providing primary
health care to urban slum population under public private
partnership by Community Based Health Volunteers in Urban
areas
• Easing up the problem of vacancies of specialists in health and
medical services:
Appointment of honorarles and part-time specialists to encouraged
private practitioners under "Samaydan scheme". As a part of this, govt.
Is actively considering the removal of age-eligibility criteria for
appointment of doctors in govt, services.
HA.
Functional Reforms
»
Extending partnership spirit with NGOs :
PHCs' and CHCs' management taken under partnership
programme with sustainable NGO for running
consideration
%
Link Couple Scheme:
10 Couples having aptitude for social work will be
selected from villages. They will act as link between
service provider and community. Good couples will be
reward In cash every quarter.. Budget is Rs. 10, 000 per
PHC per year.
*
Establishment of Quality Control Circles to
improve quality of health care services by means
of capacity building:
To improve coverage and patient satisfaction by means of
creating awareness about quality and Involvement of
Capacity Building:
The health training is being planned through
involvement of peripheral training institutes of relevant
expertise
* Establishment of Blood Transfusion
Grid/Network:
Most of the blood banks are in urban areas and operated
privately. 88 First referral units are identified in the state
to establish Networking. Blood collection and storage
facilities as per GOI guidelines will be developed at
district hospitals and FRUs. A networking of blood banks
operated by government, trust hospitals and by private
owners will be done. Facilities will be provided to these
blood banks.
««3
HEALTH SYSTEM REFORMS I N
HIMACHAL PRADESH
Besides the keenness of the State
Government to reform the Health Sector in
Himachal Pradesh, two OrganizationsGTZ (German Project) and European
Commission Programme through the
Government of India - arc supporting
reforms in the health programmes and
activities here.
I
2. ASPATAL KALYAN SAMITI extended to Sub-Divisional
level Hospitals in 2002:
a.
Provision of Seed Money to improve such facilities that
add to resource generation in the Hospitals exists:
b.
Encouraging results are pouring in.
3. Primary Health Care, Emergency Services, Niitional
Disease Control Programmes as also entire tteatment of
families living below poverty line is absolutely free. The
following is the criteria for families below BPL:
CHANGES IN FINANCING METHODS
1. Establishment of Society under the Registration of Societies
Act called ASPATAL KALYAN SAMITI at Zonal and District
Hospitals: Government letter issued on August 5, 2000
followed by Government Order issued on July 8, 2001. These
Samitis would improve:
System efficiency;
Service quality;
Patient satisfaction;
Local decisions and so initiative of the Officers;
Accountability at Hospital level;
Resource utilization;
The Hospital itself;
Resource generation through Community Financing and
User's Charges.
’
The good work that was started in 2001 was attacked from all
quarters There was opposition as is always there for any
Reforms measure. However, the results started pouring in in
2002-03 and people, now, appreciate the steps taken.
4. Major stakeholders involved and their role
a. Community and various NGOs. In some of the hospitals the
NGOs
-have adopted wards;
-provide food to the indoor patients;
-improve the infrastructure of the hospitals;
Panchyati Raj Institutions
a. They carry an IRDP card/certificate with them;
District Administration
b. The treating doctor is satisfied that the patient actually belongs
to BPL category.
Patients and Health Providers
‘14
5. Monitoring and Evaluation System
IB a
Monitoring is a regular process. One of the members of the
Samiti is a representative of the Audit and Accounts Wing of
the Finance Department;
■I®? -b. Evaluation of the working of these Samities upto the hospitals
I
at Zonal and District level was got done by HPVHA.The
recommendations of the Report are being Implemented in
order to improve the functioning of the hospitals.
6- Successes and Failures, constraints faced and
lessons learnt
I
•
It is clearly visible that the Man behind the Machine makes
the Machine workable. Where there are creative and dedicated
In-charges of hospitals, there the improvement in the hospitals
f ; is remarkable. However the improvement is State wide because
\ it is for the first time that the doctors in the hospitals have started
developing a Vision for the hospital.
...
The greatest hurdle in bringing about a change is always the
employees of the Government. They raised hullabaloo at the
time of forming the Societies.They could come to terms after
long deliberation with them.
The lesson leamt is that before jumping into a change or
Reform, all the stakeholders should be taken into
confidence after a series of discussions with them.
7.
A few other changes in financing methods are Included In
the Decentralization of Powers to Medical Officers In
PHCs. These will be discussed there.
. Changes IN HEALTH SYSTEM ORGANIZATION, DELIVERY
i
AND MANAGEMENT
While delineating the role, one major step was
Functional Integration of the Department of Indian
System of Medicine and Homeopathy and the
Department of Health and Family Welfare to follow
standard protocol in National Health Programmes was
notified. The process was streamlined in 2002-03 by
$putting into practice a defined methodology:
fi
s,
B
Granting Autonomy to hospitals has been discussed
above
a.
Decentralization of Administrative and Financial
Powers right upto the PHC level has been done.
-the BMOs have been given an imprest of Rs. 5000/-the MO/lc of PHCs have been given an Imprest of Rs.
1000/-
___
2,b.
Due to Financial crunch the MO/lc are not enjoying this
f
1
•
District Ayurveda Officers attend monthly meetings of
the GMOs;
GMOs allocate targets to the District Ayurveda Officers
in preventive and National Health Programmes;
Meetings of Sub-Divisional Ayurveda Officers and
BMOs are held for determining targets for AHCs and
PHCs;
Officers, by name, appointed in both the Directorates to
solve the problems, If any crop up, In the fields.
Training of Ayurveda Officers In National Health
Programmes and other Reforms is likely to be
undertaken In HFW Department provided the funds are
available.
Sensitisation Wrokshops for the representatives of PRIs
towards Health Related Programmes stand completed in
10 Districts. Workshops for PRI’s representatives for 2
Blocks is going on at DADH in Kangra Distt by CRRID.
2.c. Panchayati Raj Institutions are being given
adequate powers to play a vital role n health
related Activities:
•
PARIKAS (short of Parivar Kalyan Salahkar
Samiti) have been formed at all the three levels
of Panchayati Raj System:
• Panchayat PARIKAS has Pradhan of Gram
Panchayat as the President and, preferably,
Female Health Worker as the Secretary:
•
A booklet written in Hindi giving details about PARIKAS
and Health Institutions plus Health Programmes was got
published and distributed to all the representatives of the
PRIs.
•
Funds for Family Health Awareness Camps under
HIV/AIDS and those for Mahila Swasthya Sangh activities
are being given to PARIKAS now instead of the Block
medical Officers to ensure more involvement of PRIs in
health related activities.
Il
f
• Khand PARIKAS has Chairperson of the
Panchayat Samiti as the President and the
Block Medical Officer as the Secretary;
• Zila PARIKAS has the Chairperson of the Zila
as the President and the Chief MediCcil Officer
as the Secretary
5.Contractual Appointment of the Health Care Personnel.
a. The first step was to appoint Institution-specific doctors.
It was successfully done and a three-day pre-placement
training to these newly appointed Medical Officers was
given:
3.Contracting out of Select Support Services in Health
Institutions:
-Three support services; viz., scavenging, laundry, and diet
are being transferred to Private Sector, wherever possible.
4.The Private Sector is being involved in the service delivery
S only as far as the National Health Programmes are
concerned. There are a couple of hospitals in the State and
four Hospitals outside the State where the employees of the
State Government can get their treatment clone and the
expenses reimbursed to them.
-It was a much appreciated step that filled vacancies in
Health Institutions in the interior;
-Course for their pre-placement training was designed;
5
-Trainers identified;
-Training given to 73 Medical Officers.
b. The second step is to fill 100 posts of doctors and 181
posts of nurses in institutions where there is paucity of
staff.
HG
Promulgation of The H.P. Paramedical Council Bill 2003.
The objective is to maintain the State Register of
Paramedical practitioners and to prescribe a code of
ethics for them; also to register para-cllnical
establishments etc.
g Interconnectivity for MIS for collecting data
NHP/Disease Surveillance and Manpower Planning:
for
The Computers are installed in all the District Headquarters
Promulgation of H.P. Medical Council Bill 2003.
Software developed during 2002-03 (Forms 6,7 and 8) and is
currently being implemented in District Hamirpur, Bilaspur
and 4 Blocks of Kangra District on pilot basis
Himachal Health Vision 2020 adopted by the Govt as
Policy Document
I
"All Residents In the State will be enabled to be healthy, both
in mind and body Himachal will be the Dominant Provider
of total Health Care Services, including physical, mental
and spiritual Health care will be the major powerhouse of
growth and economic development in the State"
13. Registration of vital events:
10. Improving IEC and Advocacy:
<
Strengthened the IEC Wing by giving long due promotion to
certain categories of Officers.
Mi
I B
’ • The vital rates are being worked out up to Panchayat level
■ Month-wise Plan for IEC activity drawn reflecting the
s responsibilities of
various Departments and the personnel
X to cany out the activities.
|
I
I I. Writing of ACRs was streamlined.
■
.
r. ----- - ------ --'
Burden of disease survey has been conducted by the PGI,
Chandigarh. The Report has been received. The results of
the survey will help in developing proper policy and
governance.
• During the year 2002-03, the level of Registration of vital events
has gone up to 98%
. ’■sT'
v1
a-
■ ■
4 The information about District Una, Lahaul-Spiti, Shimla, Mandi
’ and Solan is computerised
-fv • t'
I
sf
I
n
■■
t__
•
■
.
^Back^ound
Health Sector Reforms
Born on 9th November 2000 .
September 4th & 5th 2003.
■
Comprises 13 Districts, 49 Tehsils , 95 Blocks
& 16414 Villages
Small scattered rural settlements.
Dr. LS. Pal
■
Director General Medical Health & Family
Welfare, Uttaranchal
50% of villages have population less then
200 & 84% less then 500
1~- arH
...J
Each sub-center serves 5-8
distance of village to sub-
villages &
center varies from 5 -
8 Kms
■ Poor road connectivity , difficult hilly terrain
(93% of area in hills), small scattered settlements
lack of infrastructure & man power contribute to
problems of access to health service delivery &
a felt need for reforms in health sector.
■
'
A. Reform Initiatives for
Primary Health Service
Delivery
Contractual Appointments
Transfer policy
Training of TBAs
Special Salary for Doctors in remote areas.
Integration with ICDS.
?■.
■;
3: Reffin. in^ives
"I
Integration with ISM&H
Fixed Day schedule for health service delivery.
Fixation of roles & responsibilities of MO at Add.
PHC.
Proposed health service delivery through
community sponsored candidates.
Mobile Van for curative services.
'
secondary health service delivery
Privatization of sanitation, laundry & diet
services.
Drug procurement policy.
Chikitsa Prabandhan Samittee in select
hospitals.
Establishment of PCOs in Govt. Hospitals
I 1
■
Reform Initiatives Taken
C. Other Initiatives
Integrated umbrella society at state level.
Integrated umbrella society at district level.
Formulation of Integrated Health & Population Policy.
Delegation of powers under 73rd Amendment tc PRls.
Appointment of 154 Medical Officers & 269 ANMs
on contract
■ Reform taken to combat problem of access
■ Service providers have been serving for more
than one year.
■ Positions in mostly remote areas.
■ Improved access to health services in these
areas.
!
>
■At present only 56 male medical officers, 11
lady medical officers & 4 dental surgeons
continuing.
WZ , .
pJ__________
J: •'
'
Transfer Policy for Medical Officers
■ Reform taken to combat problem of access
■Difficult to retain services of service
provider due to lack of accommodation &
low salary.
■ Service providers serving in remote areas to be
given soft postings & vice a versa.
■ Reform ensures availability of service provider
in remote areas.
■Preferable to take up local service providers
in future.
L
Z
Z i
■ Medical Officers posted in remote areas given
preference for PG admissions during service.
■ Specialists to be appointed in CHCs / Tehsil
Hospitals / District Hospitals.
■ Fresh recruitment of specialists by Public
Service Commission.
Reform has improved access to health
services in the State.
a
J
1
I
'at-Traininfi
■ Reform taken to combat problem of access.
■ 900 untrained dais imparted 10 day training in
2001-02 & 2002-03, & distributed DDK.
■ 800 dais to be imparted training in 2003-04
■ To reduce maternal & infant mortality.
■ To increase safe delivery & institutional
delivery.
■ Dai training has improved access to health
services.
2001-02 2002-03 Apr-Jul 03
■ Deliveries by TBA
40250 46201
12641
ia.1
■ '■
I
i:
Incentives for Service Provider in
difficult areas
Integration with ICDS Department.
■ Reform to combat problem of access.
■ Special non-practicing allowance for doctors posted in
remote & difficult areas.
"$«:}?<■ s:Uan
■
AWWs given orientation training to register ANCs & refer
high
risk cases.
■ AWWs act as depot holders & provide information on
births & deaths.
.ik'4x:.<
Mm e than 12000
12500
4000
15000
r.
1
Reform taken to combat problem of access & bring
convergence.
■
Speei.’!l NF A
Very dtfffcttlt ; BiftkuJt :
,I
tbMn tU.llUt[ HWOG-UtHW
a?
r
■AWWs responsible for providing
communicable disease information .
■ Conduct joint meeting with medical
department at District, Block & sector levels.
■ Convergence with ICDS has improved
access to health services.
■
■
,
«
.
■
Integration ofMedical Department
with ISM&H
■ Reform taken to combat access to health
services & bring convergences.
■ Service providers of ISM&H to participate in
implementation
of
National
Health
Programme.
■ Two day district level workshop planned for
Doctors of ISM&H.
f
J
4
i
Fixed Day Schedule for Services
■ ISM&H service providers to provide monthly
reports to the directorate through Chief
Medical Officers.
■ Linkages between ISM&H and Health
Department established at sector block and
district levels.
J
.
..
Thursday
- R.C.H. camps at block level PHCs.
Third Friday - Sector meetings at PHC.
■ Reform for better management of human
resources
■ Days fixed for providing services and meetings
all over the State.
■ Ensures availability of health service delivery
to clients.
■ Ensures ease of monitoring.
Tuesday - Sterilization days at district level
hospitals
Wednesday - Sub-center days. A.N.M. to provide
services at sub-centers.
Powets and
of '
Medical Officers at Add. PHCs &
SADs
Coordination with ICDS& ISM&H
Fourth Friday - Meeting at Block. Coordination
with ICDS&ISM&H
Saturday
- R.C.H. out reach session days.
Monday
- R.C.H. out reach session days for
left over sites.
First Monday - Meeting at district head quarter.
Coordination with ICDS and
ISM&H
■ Reform taken to tackle managements issues.
■ MO incharge of Add. PHCs will be controlling
officer of all service provider at sub-centers
and health supervisors working in their
territory .
■ Integration of ICDS with Medical Department
at level of Add. PHCs.
■ MO incharge of SADs to coordinate with MO
incharge of Add. PHCs in discharging their
duties.
Health Service Delivery through
Community Participation
■ Pilot Project planned with SIP support.
■ Project planned in two blocks-Jaspur in U.S. Nagar &
Prtapgragh in Tehri districts.
■ HIHT to act as mother NGO
■ Project to follow LIP initiative of HU IT which is
already operational in Tehri & Uttarkashi Districts.
■ Primary health care delivery through volunteers at
village level.
Mobile Van for curative
services
i
■ Reform initiatives for health service delivery
with public private partnership.
■
Mobile van for diagnostic & curative services
in Kumaon division.
■ Support of TIFAC (technology information
forecasting &assessment council) under
Department of science & technology, GOI.
11
r
Privatization ok Sanitation,
Laundry and diet services
■ Diagnostic & curative services provided at
fixed sites mostly in Kumaon division & some
sites in Garhwal division.
■ 50% of operational cost bourne by GO(J.
■ Mobile van operated by Birla institute of
scientific research Bhimtal.
32
■ Reform taken to improve health service
delivery.
■ GOG order to hand over laundry and diet
services in 9 big hospitals to private agencies in
December 2001
■ Agencies selected on competitive bidding.
■ Disease specific diet served in these hospitals
■ Services handed over to private agencies in
Doon Hospital in Feb 2003.
t.
T7T
T"
Statistics for Doon Hospital
after privatization
Year
OPD
? 2002
; Vp to July
i 20413
Indoor
patients
I MKK,
' 1,61.146
7.34?
Average Diet
' Distributed per J
day
45
! 150
ospital
Statistics for Doon Hospital
after privatization
OPl)
. .Month
i 2992
Man’ll ? 15565
April 18491
May |19510
.hine \17778
July !25089
IPO
12M?
2002
828
908
1182
1043
HI2
■ 22938
24638
i22998
22437
1
pS
11320
! 1114
a
Establishment of PCOs in Govt.
Hospital
■ Reform taken for client convenience & improve
health service delivery.
■ GOU Order for Telephone facility in Govt. Hospitals
with support of private PCOs.
■ PCOs selected on competitive bidding for three years.
■ Rent to be paid to hospitals by PCO.
■ Space provided by hospitals and users to pay for calls
at DOT rates.
J__
T Drug procurement policy
j
■ Reform to improve quality of service.
■ Company to have minimum turn over of 15 crores in
past three years.
■ WHO-GMP certification an essential pre-requisite.
■ Drug to be supplied by company should have been in
manufacture for minimum three years.
■ State comprehensive drug policy to be formulated by
UAHSDP
1X5
[?
Chiki^
SumHee
in Select Hospitals
■ Reform taken to bring about decentralization &
community participation.
■ Reform to also improve health service dcliveiy.
■ Chikitsa Prabandhan Samitees to be registered for 30
district level hospitals under the chairmanship of
district magistrate.
■ Representation of elected representatives in the
samitees.
■ 100% retention of user charges for utilization by
Chikitsa Prabandhan Samitee.
Intc rated sdciet at State 'Level
■ Reform initiative taken to tackle management
issues.
■ Apex Society for National Programme under the
Chairmanship
of
Chief
Secretary
for
■
implementation of National Health Programmes
with DG as member secretary.
■ Six sub-committees under the chairmanship of
secretary
medical
for
various national
programmes with DG as vice president.
Level
■ Funds flow from GO! through State Level
Society to District Empowered Committees for
implementation of National Programmes.
■ Secretariat to be setup in the campus of
Director General w'ith support for man power
and equipment.
■ Reform initiative to tackle managements
issues.
■ District Empowered Society registered in each
district.
■ Committee headed by the DM with CMO as
Vice President.
■ Fund flow from GOI through State Level
Society to District Empowered Committees for
implementation of National Programmes.
■ Secretariat to be setup in each district with
support in man power and equipment.
I.
—Forir lation oTTntegratea
Health & Population Policy.
■ Integrated policy released in Dec’2002
■ Specific Health & Population Stabilization
objectives.
■ Specific policy directions to achieve the mission
& policy objectives.
■ Specific policy interventions also identified in the
policy.
o'
.11
'■
P
Proposed delegation of powers
under the 73 rd Amendment.
■ Gram panchayat to have administrative control of
male & female workers at village level.
■ Future recruitments through Gram panchayat.
■ Block panchayat to have administrative control of
all health delivery personnel at block level.
■ Future recruitments through block panchayat
except for medical officers.
■ Chairman zila parishad to have administrative
control at district level with CMO as Add.Exec.
Officer.
1^
Major Lessons Learnt from first
phase of RCH
From First Phase to Second
Phase of RCH \
Major
tsons learnt
• Process and output indicat^tp be
agreed upfront
• Insist on monitoring systems -regularity^
and quality
\
* State ownership critical
x.
Flexibility based on state needkand
capacities
\
Adequate institutional arrangement^
need to be in place
\
Major Le
ns learnt
• Link performance to financing
• Establish linkage between RtSw and FP
services
\ X
• Management capacity to be
\
strengthened in the areas of planning,
supervision, budgeting, fund flow
\
Major L^
pns Learnt
** Program management capacity at district
levels to be strengthened especially in the
EAG states.
.
«* Need to introduce Human resource'plabnqg
forecasting requirements of human \
resources, training, posting and promotional
policies.
\
Establish client sensitive behavior in service
providers.
\
Major Les^
is Learnt
* Involve communities and loc^l elected
bodies in planning, managemeht^Fid
monitoring of program performance
Include and provide emphasis on \
neonatal health & adolescent health.\
* Involvement of private sector to
\
enhance availability of services
Major Les
ns learnt
• Clearly developed state Specific
Behavioral change strategies
• Enhance client responsivenessl RCH
services so as to introduce a demand
driven service delivery system.
\
• Improve outreach services particular^
regarding routine care and in retaining\
clients for completing the cycle of care.
Major Lessi
s Learnt
Building bridges with other critical
sectors such as Rural development,.
Urban development, sanitation, public
health, nutrition, Women & Child \
development sectors.
\
Why we need
Why we n<
** High Level of IMR and coMribution of
neonatal mortality
& Need to focus on states with high TFR.
* Address inequities in the use of service
delivery systems related to child Health,
maternal Health and essential obstetric
care in the weak states
\
RCH
VISION
the Second Phase?
Second Phase?
ND PHASE
X
The vision is to bring about outcome's,envisioned
in the National Population Policy 2000(NPP 2000),
The Tenth Plan Document, National Health Policy
2002 and Vision 2020 IrtdiiK, minimizing regional
variations in the areas of Reproductive and Child
Health and Population Stabilization through an
integrated, focused, participatory program rneenng
the unmet demands of the target population, and\
provision of assured, equitable, responsive quality
services, by adopting a mission mode.
\
* High MMR indicates the'need to
improve functional linkages^primary
care services with facilities providing
EOC/Emergency Obstetric Care and
better understanding of contributoiV
factors through maternal death audits.
* Need to improve birth spacing, skilled \
attendance during pregnancy, care and'
service during child birth and post natal
periods.
OBJECmVES
• To educate and empowebthrough
behaviour change communication and
community mobilization In improving the
health seeking behaviour.
\
• To increase
\
quality/responsive/sensitive/reliable \
service availability and improve the \
accessibility in order to improve the
\
attendance at the public health system.
<30
OBJE
VES
OBJE
VES
• Set in motion sector reforminitiatives in
order that the service availabim$rin the
public health delivery system achieve a
better perceived image among the\
population
\
• To put in place strategic initiatives to bring
about a wider role for the private sectorX
providers to enable achievement of widen
reach of services.
\
• To initiate policy changes!^ ensure
assured services at all levelsTna
equitable manner to all those who
seek services as well as enable \
initiatives hither to not possible due
to the policy environment.
\
PROPOSED STRATEGIES UNDER
RCH SECONl^PHASE
PROPOSED STRATEGIES UNDER
RCH SECONIXPHASE
Dedicated structural arrangement&do improve
program management
f:
a?'
Improved ownership among states
\
Decentralized planning and implementation
through involvement of PRIs and ULBs
\
* Strengthened system of planning, monitor!rw
and supervision
\
fl. Differential approach
Integrating referral networks
\
Strengthening quality aspects of service delivery
Enhancing coverage of ANC, New Born care,
Institutional deliveries
\
*■ Bring about a comprehensive integration of 1FP
into safe motherhood and child health
\
Inter-sectoral collaboration and convergence \
Is. Empowering structure and enabling environment
Increasing the involvement of the Private Sector'
/3I
RCH SECOND PH.
MATERNAL HEALTH
« RTI/STI
< NEW BORN AND CHILD HEALTH
COMPONENTS
X.
* ADOLESCENT HEALTH
\
\
POPULATION STABILIZATION
* URBAN HEALTH
* TRIBAL HEALTH
* NGO INVOLVEMENT
* INFRASTRUCTURE MAPPING & STRENGTHENING
* BEHAVIORAL CHANGE COMMUNICATION
* TRAINING
Design proce:
for the state
• Formation of a design team with Synodal official
to lead the process.
• Drawing experts from the state itself \
• Looking at outputs upfront
\
• Interpolating process indicators and workiha out
annual plans and budgetary requirements \
• Conducting a sector analysis
• Monitoring on the basis of performance
benchmarks as agreed upon mutually by the
state and the MoH&FW
• Drawing on good practices
• Attempting decentralization through PRIs/ ULBs
Thank you
132.
India’s Health System: Role of Health Sector
Reforms
Proceedings of September 4, 2003
A Synopsis
Ms. Anagha Khot
WHO National Comultant (HSR). MOH&FW
> Structural reforms include restructuring & re ogamzation of
existing health care infrastructure, mainstreaming of ISM&H
practitioners. Functional reforms would include horizontal
integration of programmes, integrated system for district based
administration, effective logistics system for supply of drugs
amongst others
> Financial reforms include levying of user charges, developing
alternative financing mechanisms, evolving and implementing
mechanism to ensure sustainability of ongoing govt, fimded health
programmes especially those with substantial external assistance.
> Governance related reforms would include initiatives aimed
increasing the accountability of health care providers and of the
health systems such as evolving standard protocols for care, setting
norms for cost of care, delegation of powers to PRIs.
Punjab
> Definition of HSR includes
• improving the civil service
• decentralization of power and resources
• improving function of health ministries
• broadening health financing
• increasing the role of private sector in the financing of
provisioning of health care
> Elements included under HSR:
• Privatization of health services specially at secondary & tertiary
levels
• Introduction of cost recovery mechanisms (E.g. introduction of
user fees; contracting out of ancillary services in public sector)
• Implementation of “essential services “for specified target
groups at the primary level.
• Decentralization of services financial and administrative
> Resource mobilization through user charges including its
retention & utilization at point of collection & Medical
insurance
> Decentralization (viz. handing over of subsidiary health
centres and sub-centres to PRIs)
> Outsourcing of services such as clinical, security, sanitation
and ambulance; maintenance of services and engagement of
health personnel
> Public - private partnership
> Re-vamping of primary health care services
> Health care delivery through better mobility
> Maintenance of assets and its optimum utilization
153
Rajasthan
Financing methods - Medicare Relief Society (MRS), Life Line
Fluid Stores
Changes in health system organization
•
Decentralization - District health societies
•
Granting of autonomy of hospitals / CHCs / PHCs - MRS
• Contracting out - Cleaning services in hospitals
•
Reforms related to human resources
Drug policy and procurement
Policy reforms (E.g. Population Policy, Essential Drug Policy,
Health Vision 2025, Transfer policy)
Private / NGOZ Voluntary & Public Partnerships (E.g. Jan Mangal
Scheme)
Equity enablers (BPL Medicare card scheme)
Himachal Pradesh
>
>
>
>
>
>
>
>
Creation of Block Health Office
Establishment of Emergency Obstetric care services in tribal &
inaccessible areas
Application of GIS in planning activities related to malaria control
Minor repair work in PHC/SC buildings
Appointments on contract basis - ANMs /Lab Technicians,
Staff nurses, Medical officers
■
Establishment of IEC Bureau
Regulation of private sector- Rajasthan Clinical Establishment Act
Re-organization & re-structuring of existing govt health care system
>
>
>
Gujarat
Structural Reforms
Resource Allocation
Decentralization with resource allocation & management
Establishment of Aspatal Kalyan Samiti (AKS)
Decentralization of administrative and financial powers upto PHC level
Involvement of PRIs (viz. PARIKAS) at all 3 levels of Panchayatt Raj
System
Contracting out of select support services in health institutions
Contractual appointment of health care personnel
Promulgation of HP Paramedical Council Bill 2003
Interconnectivity for MIS for collecting data
Improving EC and advocacy
Registration of vital events
Re-organization and re-structuring of existing government system
Reforms related to human resources
.
Merging of all Health & Family Welfare Societies
.
Managerial skill up-gradation of senior officers
.
Capacity building of MOs in proper utilization of power
Functional Reforms
Public private partnership
Extending partnership spirit with NGOs
Community based health volunteers in urban areas
>
>
>
Link Couple Scheme
Establishment of Quality ConUol Circles to improve quality of health care
services by means of capacity building
Contracting out of services for IEC
Re-organization of infrastructure Establishment of blood transfusion
grid/network
Uttaranchal
> Reforms at primary health service delivery
• Contractual appointments
• Transfer policy
• Training of TB As
• Special salary for doctors in rural areas
• Integration with 1CDS, ISM&H
. Fixed day schedule for provision of services
Reforms at secondary health service delivery
• Privatization of sanitation, laundry & diet services
• Drug procurement policy
. Establishment of Chikitsa Prabandhan Samiti
. Establishment of PCOs in government hospitals
> Integrated society at State and district level
> Delegation of powers under the 73ri Amendment
Issues and challenges
> State has to continue as a provider of services. The basic goal of
providing a reasonable standard of health to all citizens with the
underlying principles of equality, equity and comprehensive care
should lead the reform process.
> A clear picture of the current scenario in the health sector & a
situational analysis at national & regional level relating to content and
process of HSR would be one of the pre-requisites for ensuring
successful implementation of HSR. The linkages between the various
components of health system, logistics of availability and accessibility
to services, manpower, drugs have to be ensured. Accountability of
public and private providers is essential to enhance efficient delivery
of services.
> Emphasis should be laid on the process of reforms along with
the content. Lack of adequate process documentation of HSR
in India was identified as one of the gaps. Further studies
would be required across various components of HSR to
assess their impact and to emulate the ‘success’ stories and
learn from failures.
> Monitoring and evaluation mechanisms need to
incorporated right from the point of initiation of reforms.
be
> Adequate mechanisms for collecting data for review and
documentation need to be built in.
> There is a plurality of experiences among the states as far as
HSR are concerned. We can learn from the experiences as to
what works as a reform and the possible obstacles that may be
there in the process. A suggestion was received on ongoing
sharing of experiences across states in a web enabled format.
> Ensure participation of all stakeholders in the reform process
from its conception.
> Capacity building of stakeholders at different levels would be
critical
> Need exists for the Centre to play a more pro-active role in the
area of HSR
> Need to identify the next steps
I3S
List of Participants
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
Workshop on
INDIA’S HEALTH SYSTEM: ROLE OF HEALTH SECTOR REFORMS
SEPTEMBER 4 & 5th, 2003
List of Participants
Ministry of Health & Family Welfare
Shri Prasanna Hota
Secretary, Family Welfare
Nirman Bhawan
New Delhi
Telefax: 011-23018887
Email: puruhota@hotmail.com
Dr. S.P. Agarwal
Director General, Health Services
Nirman Bhawan
New Delhi__________________
Smt. P. Jyoti Rao
Addl. Secretary
Nirman Bhawan
New Delhi__________________
Shri Anurag Goel
AS&FA
Nirman Bhawan
New Delhi
Tel: 011-23019673____________
Smt. M. Dutta Ghosh
Additional Secretary &
Project Director, NACO
Room 254-A, Nirman Bhawan
New Delhi
Tel: 23019066/23325331
Email: mdg@naco.org_________
Dr. P. L Joshi
Addl. Project Director, NACO
NACO
36 Janpath, Chandralok Building
New Delhi
Telefax: 011-23325337
Email: doctorioshi@yahoo.com
Dr. Rachel Jose
DDG (O)
Room 342-A, DGHS
Nirman Bhawan
New Delhi
136
Telefax: 011-23014594
Email: ddgo@nb.nic.in_____
Dr. Urmil Mahajan
DDG (Planning)
Room 252-A, DGHS
Nirman Bhawan
New Delhi
Telefax: 011-23017467_______________
Dr. Ashok Kumar
DDG (Leprosy)
DGHS
Nirman Bhawan
New Delhi
Telefax: 011-23012401
Email: ddgl@nb.nic,in___________
SmtUrvashi Sadhwani
Additional Economic Adviser
Room 449-A
Nirman Bhawan
New Delhi
Telefax: 011-23015028
Email: aeabop@nb.nic.in
Ms. Anagha Khot
WHO Consultant (Health Sector Reforms)
Room 523-A,Nirman Bhawan
New Delhi
Tel: 98912-54412
Email: anagha khot@rediffmail.com____
Shri A. K. Puri
Media Officer
Ministry of Health & Family Welfare
Nirman Bhawan
New Delhi
Tel: 011-23014155___________________
Shri R. B. Gupta
WHO Consultant
Room 352- A Wing
Nirman Bhawan
New Delhi
_________________
Shri Rakesh Maurya
AD (TD)
Nirman Bhawan
New Delhi
Participants from States
Dr. R. N. Mahanta
Nodal Officer, SSRC & Dy. Dir (H)
SDA Complex - Kasumpty
Shimla - 9, Himachal Pradesh
Tel: 0177-2621720 (O)
Fax: 0177-2621720
137
Email: parimahalshimla@hotmail.coin_________
Dr. B. Sekhar
Special Secretary Medical & Health
Secretariat, Jaipur 302004
Rajasthan
Tel: 141-3124866
Email: bsekar63@Yahoo.com________________
Shri S. K. Nanda
Secretary (Health)
Sachivalaya, Plot 528/2, Near CH-2 Bus Stop,
Sector 8, Gandhinagar 382008
Gujarat
Tel: 079-3224394
Email: sknanda56@hotmail.com______________
Dr. I. S. Pal
Director General (Medical & Health)
Chandra Nagar,
Dehradun
Uttaranchal
Tel: 0135-2720311_________________________
Dr. J Datta
Officer Incharge, Dte. General (Medical & Health)
Chander Nagar,
Dehradun
Uttaranchal
Tel: 0135-2720311 /2720170_________________
Dr. Anjali Bhawra, MD PHSC
Punjab Health Systems Corporation (PHSC)
Chandigarh, Government of Punjab
Tel : 633124
Email: abhawra@hotmail.com________________
Dr. Rajinder Singh Saggu,
Director
Punjab Health Systems Corporation
341-342, Sector 34,
Chandigarh
Tel: 665023
Other Participants
Dr. S.J. Habayeb
WHO Representative to India
534, A Wing, Nirman Bhawan
Maulana Azad Road
New Delhi 110011______________________
Shri N. K.Sethi
Dean
National Institute of Health & Family Welfare,
New Mehrauli Road, Munirka
New Delhi - 110 067
Tel: 011 -26165959 / 26107773
Fax: 011-26101623
138
Email: nihfw@mantraonline.com
Shri BBL Sharma
Reader, Health Economics
National Institute of Health & Family Welfare,
New Mehrauli Road, Munirka
New Delhi - 110 067
Tel: 011-26165959
Fax: 011-26101623
Email: bblsharma@yahoo.com
Dr. Ambujam Nair Kapoor
DDG
V. Ramalingaswami Bhawan
Ansari Nagar
New Delhi - 1 10029
Tel: 011-26588296
Fax: 011-26588896
Email: ambujam k@hotmail.com
Shri Vijay Pillai
Programme Manager,
DFID India
British High Commission
B 28, Tara Crescent
Qutub Institutional Area
New Delhi 110016
Tel: 011-26529123 (Ext. 3309) / 52793309
Fax:011-26529296
Email: y-Pillai@dfid.gov.uk______
Ms. Suneeta Singh
Sr. Public Health Specialist
70 Lodhi Estate
New Delhi 110003
Tel: 011-24617241
Fax: 011-24619393
Email: ssingh6@worldbank.org
Ms. Yasmin Zaveri Roy
Programme Manager
Embassy of Sweden
Nyaya Marg, Chanakyapuri,
New Delhi 110 021
Tel: 011-24197125
Fax: 011-26885540
Email: yasmin.zaveri-rov@foreign.ministry.se
Ms. Eileen Stewart
First Secretary (Development)
Canadian High Commission
Development Cooperation Section 7/8,
Shantipath, Chanakyapuri
New Delhi 110021
Tel: 011-26876500
Fax: 011-26886478
139
Email: eileen.stewart@dfait-maeci.gc.ca___________________
Ms. Diana Rosenow
Health Sector Advisor
EC Delegation
65, Golf Links
New Delhi
Tel: 011-24629237
Email: diana.rosenow@cec.eu.int_________________________
Ms. Sara Joseph
Researcher
ECTA
D-127 Panchsheel Enclave
New Delhi
Tel: 011-26490204
Email: sara@echfwp.com_______________________________
Ms. Vichitra Sharma
Media Manager
ECTA
D-127 Panchsheel Enclave
New Delhi
Tel: 9811509797
Email: yichitra@echfwp.com____________________________
Ms. Srilakshmi Divakar
Room 223, Sabarmati
Jawaharlal Nehru University
New Delhi
Tel: 9810461205
Email: divakarl5@hotmail.com__________________________
Resource Persons / Experts
Dr. Prema Ramachandran
Advisor Health
Planning Commission
Government of India
Yojana Bhavan, Sansad Marg
New Delhi- 110001
Telefax: 011-23096590
Email: prema ramachandran@yahoo.com
Dr. Rama Baru
Associate Professor
School of Social Sciences
Centre for Social Medicine and Community Health
New Delhi
Tel: 011-26197710
Email: baru@ndb.vsnl.net.in__________________
Shri J.P. Misra
Programme Adviser
EC Health & Family Welfare Sector Prog. In India
D - 127, Pansheel Enclave
New Delhi 110017
Tel: 011-26490204/26490227
140
fl
Fax: 011-26498234
Email: mishra@echfwp.com____________
Dr. Tej Walia
Regional Adviser
Health Systems Development (HSD)
WHO Regional Office for South East Asia,
World Health House
Indraprastha Estate, M.G. Marg,
New Delhi 110002
Tel: 011-23370804 (Ext. 26333)
Email: waliat@whosea.org_____________
Shri Sunil Nandraj
National Professional Officer
Evidence & Information for Policy
534, A Wing, Nirman Bhawan
Maulana Azad Road
New Delhi 110001
Tel: 011-23015926/27
Email: nandrajs@whoindia.org_________
Smt Nandita Chatterjee, IAS
NPO (RCH)
517, A Wing, Nirman Bhawan
Maulana Azad Road
New Delhi 110001
Tel: 011-23018809
Fax:011-23012450
Email: chatterjin@searo.who.int _________
Dr. Indrani Gupta
Associate Professor
Institute of Economic Growth
University of Delhi Enclave,
North Campus
Delhi-110007
Tel: 011-27666946
Fax: 011-27667410
Email: jndrani@ieg.ernet.in____________
Shri Javid Chowdhury
D 202, Anand Lok,
Mayur Vihar Phase I,
New Delhi 110091
Tel: 011-22793483 / 22792013
Email: shamaf@vsnl.net ________
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