31 st Annual Conference an Association of Preventive and Social Medi lth Sector Reforms:Relevance for In 27 th February 2004 Dr. Dinesh Agarwal, M.D., Technical advisor (Reproductive Health) UNITED NATIONS POPULATION FUND, INDIA
31st Annual Conference Indian Association of Preventive and Social Medicine
Health Sector Reforms:Relevance for India27th 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 informalWide settings
Preventive and Promotive Care
Immunization, Family Planning
Financing mechanisms
Governments, Out of pocket,Insurance
Contd……
Health System in India : Constituents
Input ProducersMedical,Nurs.collegesPharma, diagnosticInstruments
Planner and Health Managers
PEOPLE , INSTITUTIONS ANDACTORS 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 setsHealth 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 ofHealth system performanceThese are means to an end
Source: GHRR-HSPH, 2003
Efficiency
Using resources in the best possible manner to achieve goalsTechnical 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 performas desiredSeveral Definitions,framework and approachesNo term is health systems more abusedMultiple players-Management,Insurance comp.
providers,Clients and CommunityCausality important-Influences both health status/Satisfaction–widely discussedClinical and Service quality dimensionDifferent budgets give different quality!!
Quality of Health Care in India Public/Private Systems
Hospital Care Quality: ALOsAmbulatory Care: Multiple VisitsPreventive and Promotive
Use of Clinical Care protocols, guidelinesQuality of equipments, supplies and MedicinesService Quality Issues:
PrivacyConfidentialityAmenities
HIGHLY VARIABLE:WORLD CLASS to THIRD CLASS
Access
Availability of ServicesEffective Availability
Socio-culturalEconomicDistance
Utilisation (Marker of Demand)
Ability of Clients to use services they wish to use!
Access : Example
1. Availability of women providers at SCs/Outreach2. Are visits regular/predictable – “Up-down” Phenomena3. Gender of providers, culturally appropriate:Jargon4. Economic access – Opportunity Cost – Flexible payment5. Utilisation – distance factor6. What is the package of services?7. Can poor women negotiate use of health services??
Womens access to Primary Reproductive Health Care
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, EpidemiologicalTransition, 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 Difficult2. Often consequences of actions are difficult to
predict3. Doing better for one goal may not necessarily
lead to improvement in other goals4. Resistance to “Change” “Status quoists”5. Those who can benefit from reforms are not
powerfully/less organised
THANKS