Transcript Document

31st Annual Conference
Indian Association of Preventive and Social Medicine
Health Sector Reforms:Relevance for India
27th February 2004
Dr. Dinesh Agarwal, M.D.,
Technical advisor (Reproductive Health)
UNITED NATIONS POPULATION FUND, INDIA
Scope of Presentation
 Health Sector in India and Characteristics
 Health System Outcomes: Ultimate and
Intermediate
 What are reforms?
 Do we need reforms in Health Sector?
 Building A Reforms Agenda for India
 Conclusions
Health System in India : Composition
 Treatment providers
Different pathies,
Formal and informal
Wide settings
 Preventive and
Promotive Care
Immunization,
Family Planning
 Financing
mechanisms
Governments,
Out of pocket,Insurance
Contd……
Health System in India : Constituents
 Input Producers
Medical,Nurs.colleges
Pharma, diagnostic
Instruments
 Planner and Health
Managers
PEOPLE , INSTITUTIONS AND
ACTORS WHO WORK FOR
HEALTH
Health System in India : Characteristics
 Vast and Complex: Multiple Planners and
number of providers
 21% of Global burden of Diseases
(16% population)
 25% of all Maternal Deaths
Contd……
Health System in India : Characteristics
 Conflicts : Patient Care, Training and
Research
 Politics Influences: Goals, Priorities and
Strategies: Variations in Commitment
 Evolution of Health System reflect culture,
history and norms
Goals of Health System
1. Health Status of Population
 Life Expectancy
DALYs lost
Morbidity and Mortality rates
Contd……
Goal of Health Systems
2. Customer Satisfaction/Systems responsiveness
 Client Satisfaction (NFHS)
May depend on non-clinical aspects of care
Difficulty in measurement
Contd……
Goal of Health Systems
3. Financial Risk Protection
 Are People protected against high cost of
medical care?
Catastrophic Illnesses – Poor People
How are we doing ?
 Improved Life Expectancy:Yet averages mask
equity perspectives ( Class, regional &gender)
(49 years in 1970 to 63 years in 1998)
High mortality and burden of diseases among
poor: IMR,Diarrhea Diseases etc
Client Satisfaction:
“High” level in large scale data sets
Health Sector most corrupt
(Transparency International)
Contd……
How are we doing ?
 Overall Government spending 0.9% GDP –
Bottom quintile in world( WHO 2001)
Private Expenditures: 80% of all spending on
health
Nearly 40% of hospitalized in 1995-96
fell into debt.
Large Scale Inter-State Variations: Risk of
falling in debt after hospitalization
(17% in Kerala – Double in UP/Bihar)
Ref: Mehal et al 2001
Delivery of Public Health Services: Who uses??
1. Richest quintile consumes 3 times more public
health resources as compared to poor
2. Most States reflect “Pro-rich” distribution
3. Health needs of urban poor, marginalized
and Tribal population
Intermediate Outcomes of Health Systems
 Efficiency
 Quality
 Access
 Financial Burden
These are widely discussed characteristics of
Health system performance
These are means to an end
Source: GHRR-HSPH, 2003
Efficiency
Using resources in the best possible manner
to achieve goals
Technical Efficiency: How do we produce
Output/s?
Allocative Efficiency: What we produce?
While TE is essence of management, AE is more
linked to political economy of health
Example: Maternal Mortality in India
Quality
Degree to which goods and services perform
as desired
Several Definitions,framework and approaches
No term is health systems more abused
Multiple players-Management,Insurance comp.
providers,Clients and Community
Causality important-Influences both health
status/Satisfaction–widely discussed
Clinical and Service quality dimension
Different budgets give different quality!!
Quality of Health Care in India
 Public/Private Systems
Hospital Care Quality: ALOs
Ambulatory Care: Multiple Visits
Preventive and Promotive
 Use of Clinical Care protocols, guidelines
Quality of equipments, supplies and Medicines
Service Quality Issues:
Privacy
Confidentiality
Amenities
HIGHLY VARIABLE:
WORLD CLASS to THIRD CLASS
Access
Ability of Clients to use services they wish to use!
 Availability of Services
Effective Availability
Socio-cultural
Economic
Distance
Utilisation (Marker of Demand)
Access : Example
Womens access to Primary Reproductive Health Care
1. Availability of women providers at SCs/Outreach
2. Are visits regular/predictable – “Up-down”
Phenomena
3. Gender of providers, culturally appropriate:Jargon
4. Economic access – Opportunity Cost – Flexible
payment
5. Utilisation – distance factor
6. What is the package of services?
7. Can poor women negotiate use of health services??
Source: Gender Mainstreaming in RCH II – A Report
National Context for Reforms
1. Demographic Transition
(Shift from high fertility/mortality to low
mortality and fertility)
2. Epidemiological Transition( Disease Patterns)
3. Social Transition – High Expectations
4. Technological Transition – Rapid diagnostics,
Therapeutic modalities
5. Health Systems performance problems widely
Acknowledged
6. Demand for increasing allocation (NHP)
What do we mean by “HSR”?
“Purposeful” efforts to change the system to
improve its performance
 Rational/logical
 Specify goals
 Use evidence based strategies
 Limited “r”eforms: Small changes
 Big bang “R”eforms: Sweeping changes
Source: GHRR-HSPH, 2003
Reforms Agenda for India
1. Health Policy Process –
Decentralization, devolution, delegation:
“ONE SIZE DOES NOT FIT ALL”
2. Content: Comprehensive, Epidemiological
Transition, Standards,private sector
3. Oversight function – Regulation
(Clinical establishment, PNDT, HOT Acts)
4. Health Financing Options
Barriers to “Reforms”
1. Reforms are “Hard” Choices: Truly Difficult
2. Often consequences of actions are difficult to
predict
3. Doing better for one goal may not necessarily
lead to improvement in other goals
4. Resistance to “Change” “Status quoists”
5. Those who can benefit from reforms are not
powerfully/less organised
THANKS