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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 Different pathies, Formal and informal Wide settings • Treatment providers Immunization, Family Planning • Preventive and Promotive Care Governments, Out of pocket,Insurance • Financing mechanisms Contd……
Health System in India : Constituents Medical,Nurs.colleges Pharma, diagnostic Instruments • Input Producers • 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 Health Status of Population • Life Expectancy • DALYs lost • Morbidity and Mortality rates Contd……
Goal of Health Systems Customer Satisfaction/Systems responsiveness • Client Satisfaction (NFHS) • May depend on non-clinical aspects of care • Difficulty in measurement Contd……
Goal of Health Systems 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?? • Richest quintile consumes 3 times more public health resources as compared to poor • Most States reflect “Pro-rich” distribution • 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 Availability of women providers at SCs/Outreach Are visits regular/predictable – “Up-down” Phenomena Gender of providers, culturally appropriate:Jargon 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 • Demographic Transition (Shift from high fertility/mortality to low mortality and fertility) • Epidemiological Transition( Disease Patterns) • Social Transition – High Expectations • Technological Transition – Rapid diagnostics, Therapeutic modalities • Health Systems performance problems widely Acknowledged • 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 • Health Policy Process – Decentralization, devolution, delegation: “ONE SIZE DOES NOT FIT ALL” • Content: Comprehensive, Epidemiological Transition, Standards,private sector • Oversight function – Regulation (Clinical establishment, PNDT, HOT Acts) • Health Financing Options
Barriers to “Reforms” • Reforms are “Hard” Choices: Truly Difficult • Often consequences of actions are difficult to predict • Doing better for one goal may not necessarily lead to improvement in other goals • Resistance to “Change” “Status quoists” • Those who can benefit from reforms are not powerfully/less organised