Health Sector Reforms

Health Sector Reforms: 

Health Sector Reforms State Institute of Health and Family Welfare, Jaipur

Health Sector Reforms: 

Health Sector Reforms What do we mean by reforms? What are the essential components of reforms? How do reform differ from normal evolutionary system changes? 2 SIHFW: an ISO 9001: 2008 certified Institution

Health System: Challenges: 

Health System: Challenges Stagnant public spending on health Between 75-90% spending by states Curative public services favor the rich Hospitalization frequently means financial catastrophe Poor outcomes HR shortage Cost 3 SIHFW: an ISO 9001: 2008 certified Institution

Genesis of HSR: W DR 1993 - Approaches: 

Genesis of HSR: W DR 1993 - Approaches Fostering environment enabling households to improve health Improving Government spending on Health Promoting diversity and competition 4 SIHFW: an ISO 9001: 2008 certified Institution

Hsiao’s 5 control knobs, 2000 : 

Hsiao’s 5 control knobs, 2000 5 SIHFW: an ISO 9001: 2008 certified Institution

Health Sector Reforms Definitions: 

Health Sector Reforms Definitions Sustained, purposeful, Fundamental change to improve the efficiency, equity and effectiveness of the health sector. Berman,1995 A process that seeks changes in health sector policies, financing, and organization of services, as well as the role of government, to reach national health objectives. Population Council,1998 6 SIHFW: an ISO 9001: 2008 certified Institution

Health Sector Reforms Definitions: 

Health Sector Reforms Definitions Health sector reform includes: Improving the performance of civil service Decentralization of power and resources Improving function of national health ministries Broadening health financing mechanisms Introducing managed competition Privatization Cassels (1997) 7 SIHFW: an ISO 9001: 2008 certified Institution

HSR: 

HSR Health sector reform is deliberate, planned and intended to make long term, permanent changes, rather than ad hoc or emergency action 8 SIHFW: an ISO 9001: 2008 certified Institution

Plurality of definitions: 

Plurality of definitions “Health sector reform is nothing more than projects that have been put together and it is tied to loans from the World Bank.” (Interview former Secretary of MOHFW May 2002). 9 SIHFW: an ISO 9001: 2008 certified Institution

Plurality of definitions: 

Plurality of definitions A senior official of The World Bank views health reforms as a “group of projects that includes communicable diseases, Reproductive and Child Health program and Health Systems” The motivation for health sector reform as seen by the World Bank is to “promote economic efficiency, quality, reform of public sector” (Interview with Senior Bank Official, The World Bank Delhi Office, March, 2002). 10 SIHFW: an ISO 9001: 2008 certified Institution

Plurality of definitions: 

Plurality of definitions The EC - health sector reform is nothing more than a “mixed bag of donors, projects and the government of India. Overall there is a singular lack of vision among all these actors when it comes to health sector reform.” (Interview with Senior Official, European Commisssion, Delhi office, March 2002). They consider the World Bank to be setting the agenda guided by “some North American consultants to introduce privatisation and have designed the components of the health sector reform agenda for the country”. (Interview with Sr. official, EC Delhi office, March, 2002)” 11 SIHFW: an ISO 9001: 2008 certified Institution

Dynamics of HSR: 

Dynamics of HSR Shift in international thinking – public to private provision Explore possibility of private sector participation Reduction in Government expenditure User charges Contracting out services Tax reforms 12 SIHFW: an ISO 9001: 2008 certified Institution

Major Issues: 

Major Issues Definition—incremental not fundamental The ‘project approach’ to health sector reform Spaces are available for negotiations at both the central and state levels with multilateral agencies. Fiscal crisis at state governments - health is not a high priority area of investment, Loans from bank- poor repayment capacity. Reform process is a ‘top-down approach’. There is little consultation with the personnel at different levels of the health 13 SIHFW: an ISO 9001: 2008 certified Institution

Major Issues: 

Major Issues Little co-ordination among donors(own priorities and agendas) on health sector reform. Duplication and adhocism ‘ rights based approach’ (RCH) after ICPD not effectively transferred to the different levels of providers. New budget? 14 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Principles: 

HSR: Principles Overseeing the needs of the entire population – pro-poor; gender sensitive and client friendly. Looking forward to the health transition Removing the blind spot to the private sector Focusing efforts – by ensuring quality, efficiency and accountability of health services 15 SIHFW: an ISO 9001: 2008 certified Institution

HSR Influencers: 

HSR Influencers Epi. Transition-Changing health scenario Macroeconomic situation Political environment Policy changes Increasing expectations Reducing resources and external influences Donor initiatives 16 SIHFW: an ISO 9001: 2008 certified Institution

Key issues in HSR: 

Key issues in HSR Equity Effectiveness Efficiency Quality Sustainability in provisioning Defining priorities Refining policies Reforming institutions 17 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Key elements : 

HSR: Key elements Structural rather than incremental/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 government. 18 SIHFW: an ISO 9001: 2008 certified Institution

What needs to be addressed: 

What needs to be addressed Human resource Fiscal allocations Capacity building Process monitoring 19 SIHFW: an ISO 9001: 2008 certified Institution

Functions covered by HSR: 

Functions covered by HSR Governance Provisions Financing Resource Generation 20 SIHFW: an ISO 9001: 2008 certified Institution

Basic dilemmas in HSR: HR: 

Basic dilemmas in HSR: HR CHC DH PHC No. Distribution Courses Intake Output Graduates & PG? IPHS 21 SIHFW: an ISO 9001: 2008 certified Institution

Health Manpower (31.03.07) (Source: National Health Profile, 2008): 

Health Manpower (31.03.07) (Source: National Health Profile, 2008) 22 SIHFW: an ISO 9001: 2008 certified Institution

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23 SIHFW: an ISO 9001: 2008 certified Institution

Medical Education (Source MCI/DCI/INC, 2009): 

Medical Education ( Source MCI/DCI/INC, 2009) Colleges India Rajasthan Medical Colleges 300 10 Recognized 211 7 Non Recognized 89 3 Dental Colleges 290 13 Recognized 154 8 Non Recognized 136 5 24 SIHFW: an ISO 9001: 2008 certified Institution

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25 SIHFW: an ISO 9001: 2008 certified Institution

Basic dilemmas in HSR: Financial allocations : 

Basic dilemmas in HSR: Financial allocations States – 10% of GDP. Not in a position to increase allocations Loan repaying capacity of states – increase financial burden. Frequent leadership changes affecting reforms. Corruption - an additional impediment to sustainability of reforms Need for more effective donor coordination 26 SIHFW: an ISO 9001: 2008 certified Institution

Approach for HSR: Change in Financing Mechanism: 

Approach for HSR: Change in Financing Mechanism User charges Community financing Insurance Private participation Increasing resource allocation 27 SIHFW: an ISO 9001: 2008 certified Institution

Governance related HSR: 

Governance related HSR Evolving standard protocols for care at Pri./Sec./Tert. care settings Quality assurance mechanism Consumer Protection Act Citizens charter for hospitals; Appropriate delegation of power to PRI’s. 28 SIHFW: an ISO 9001: 2008 certified Institution

Approach for HSR: 

Approach for HSR Public sector reforms Downsizing Public sector Productivity improvement Competition Improving geographic reach Increasing role of local Govt.(PRIs) 29 SIHFW: an ISO 9001: 2008 certified Institution

Approach for HSR: Changes in Health system Organization & Mgt. : 

Approach for HSR: Changes in Health system Organization & Mgt. Decentralization Public private mix Contracting out of services 30 SIHFW: an ISO 9001: 2008 certified Institution

HSR in India: 

HSR in India Started in early 1990’s Piecemeal and incremental Gradual shift in the organization, structure and delivery of health care 31 SIHFW: an ISO 9001: 2008 certified Institution

HSR in India: 

HSR in India 8 th FYP Free medical care User chargers Private sector promotion 9 th FYP Enabling PRI Focus on public, private and voluntary sector 32 SIHFW: an ISO 9001: 2008 certified Institution

HSR in India: 

HSR in India 10 th FYP Equity Financing health care Health insurance for BPL HRD Capacity building Integration – single society Quality assurance PRI empowerment PPP NRHM 33 SIHFW: an ISO 9001: 2008 certified Institution

HSR: India: 

HSR: India NRHM Architectural corrections in delivery systems in reform agenda Promote equity, efficiency, quality and accountability Enhance community based approaches to health Ensure public health focus Promote new innovations, methods & new approaches Decentralize and involve local governing bodies District health societies NGO involvement Integration of ISM(AYUSH) 34 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Areas: 

HSR: Areas Decentralization Human Resources Financial reform Re-organization & re-structuring through mgt. input Communitization Quality assurance Convergence Public Private Partnership Governance Innovation/ initiatives 35 SIHFW: an ISO 9001: 2008 certified Institution

Decentralization: 

Decentralization Devolution of authority and responsibility Delegation of responsibility and functions Shifting power from the central offices to peripheral offices Merger & formation of Societies, VHSC, RKS Decentralization of Planning Process Decentralization of Financing mechanism NGO participation in National Health Programs 36 SIHFW: an ISO 9001: 2008 certified Institution

HSR: HR Reforms: 

HSR: HR Reforms IPHS norms 2 ANMs/sub-center and 1 male MPW. 3 nurses/ANMs per PHC, 2 MO AYUSH staff 9nurses/CHC plus 5 specialists & 3 to 4 MO Expanding available skilled human resource Teaching institution through PPP More government seats in private medical colleges Reviving ANM and MPW training centers 37 SIHFW: an ISO 9001: 2008 certified Institution

HSR: HR Reforms : 

HSR: HR Reforms Compulsory rural postings Rural health service cadre in rajasthan Contractual appointments Fair transfer policy- rotational postings Incentives for difficult areas ‘Pooling’ of medical officers Multi skilling option for existing staffs 38 SIHFW: an ISO 9001: 2008 certified Institution

Financial Reforms: 

Financial Reforms Raise the public expenditure on health from 1% of GDP to 2-3% of GDP Currently increased from .9% to 1.4% New financing mechanisms of untied funds, breaking the traditional Treasury route, Flexi pool Society mechanism for fund transfer Untied grants to village, PHC, block, district 39 SIHFW: an ISO 9001: 2008 certified Institution

Financial Reforms: 

Financial Reforms Demand side finance through Insurance RSBY, Conditional cash transfers (JSY) Flexible financial resources to ensure service guarantees State Government’s increase their allocation by 10 % every year and also contribute 15% to NRHM. 40 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Structural Re-organization : 

HSR: Structural Re-organization Creation of Societies- bypass regular government Procedure National/ State level technical support organization like– NIHFW, NHSRC, SHSRC, SIHFW SHSRC established/ in process at Chhatisgarh, Gujarat, Uttarakhand, Punjab, Karnataka, AP, Rajasthan Emergency response systems- 108, EMRI 41 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Structural Re-organization : 

HSR: Structural Re-organization Procurement initiatives – TNMSC, KMSC, Assam, UP National HMIS Meaningful partnerships with the non-governmental providers for reaching quality health care Co location of AYUSH in 7244 PHCs/CHCs/District Hospitals 42 SIHFW: an ISO 9001: 2008 certified Institution

Communitization : 

Communitization Community accountability through RKS/RMRS and community monitoring process Community Health volunteer – ASHA PRI involvement in health care Village health & nutrition days (VHND) 43 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Quality Assurance : 

HSR: Quality Assurance New standards for government facilities IPHS ISO process, NABH & NABL standards Focus on service guarantees 44 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Convergence: 

HSR: Convergence Bridging the gaps between link dept Envisaged horizontal and vertical linkages within Health sector Intra sectoral and Inter sectoral integration Mainstreaming of AYUSH 45 SIHFW: an ISO 9001: 2008 certified Institution

HSR:PPP options as HR solutions : 

HSR:PPP options as HR solutions Contracting-in options – Specialists (MP) Contracting-out options – PHCs to Karuna trust in Arunachal Pradesh, Bihar(diagnostics & district planning); Gujarat (CHIRANJEEVI);Punjab( village level dispensaries) 46 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Rajasthan: 

HSR: Rajasthan Jan Mangal Project 1992 Population Mission Strengthening FRU’s 1994-2001 Decentralized District Planning since 1995-96 RMRS- Cost recovery mechanism- user charges since 1995-96 Life line fluid stores Mukhya Mantri Jeevan Raksha Kosh BPL medicare cards 47 SIHFW: an ISO 9001: 2008 certified Institution

HSR: Rajasthan: 

HSR: Rajasthan Devolution of Powers to PRI’s - 90’s Population Policy, 2000 Preparation of EDL, 1996,2000 “Policy to promote private sector in Health care facilities-2006” Policy for contracting out PHC/ CHC to private sector 48 SIHFW: an ISO 9001: 2008 certified Institution

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Special recruitment drive with hard duty allowances Sanjivani scheme -specialist services in tribal and desert areas through health camps Swasthya Chetna Yatra Mukhya Mantri Balika Sambal Yojana Free Medicines to senor citizens, BPL and pregnant women in up to 50 bedded CHCs Promotion of generic medicines 49 SIHFW: an ISO 9001: 2008 certified Institution

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Doctor aap ke Dwar Yojana: 52 MMUs Charak Aapke Dwar Yojana: free surgical services at rural areas Rajasthan University of Health Sciences MoU with North Shore Hospital, New York for up gradation of infrastructure in health care institutions and medical research cooperation 50 SIHFW: an ISO 9001: 2008 certified Institution

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Telemedicine (ISRO support), 6 medical college hospitals with 32 district hospital and 1 block Policy to promote private investment in Health Care Facilities Contractual appointments 3 Months anesthesia training Rural Health service cadre 51 SIHFW: an ISO 9001: 2008 certified Institution

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Thank You For more details log on to www. sihfwrajasthan.com or contact : Director-SIHFW on sihfwraj@yahoo.co.in