Health Sector Reforms prersentation

Presenter Moderator

Dr M A Bashar Dr Tarundeep

Junior Resident Assistant Professor

Reforms

o ‘Fundamental rather than an incremental

change, which is sustained rather than one off,

and also purposive’ (Cassels1997)

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Health System

• Health system means the "combination of resources,

organization, financing, and management that culminates in the

delivery of health services to the population"

(Roemer 1991)

• The key institutional components of the health system are:

– State or government institutions

– Health care providers

– Resource institutions

– Purchasers of health care such as insurance agencies

– Other sectoral agencies e.g., education, water supply, sanitation

– Consumers or population at large

Background

• Health sector reforms have generated much debate in India,

especially in the context of economic liberalization.

• The World Bank intensified this debate in 1993 when it tried

to redefine the role of the public and private sectors in

healthcare.

• There is no consistent and universally accepted definition of

what constitutes Health Sector reforms thereby leading to

varied meaning and connotations.

Definition

• “Sustained purposeful change to improve the efficiency,

equity and effectiveness of the health sector”

– Peter Berman (1995)

• “Defining priorities, refining policies and reforming the

institutions through which those policies are implemented”

– Cassels (1997)

Definition

• Health sector reforms is a sustained process of

fundamental change in policy and institutional

arrangements, guided by government and designed to

improve the functioning and performance of health

sector and ultimately the health status of the

population.

-WHO

Introduction

o Changes that affect at least two of these

elements:

o health financing

o Expenditure

o Organization regulation

o Consumer behavior.

• If we change only health financing its not health

sector reform

(William Hsiao)

Introduction

• In recent years, economic pressures on the government and

specifically on the health sector have forced the

governments of developing countries to initiate health sector

reforms.

• This thrust is made to ensure that an appropriate share of

public funds is spent on health care, especially at local

levels (allocative efficiency).

• It is designed to improve the organization and management

of health systems and ultimately to achieve overall health

policy objectives.

Introduction

• The users should also be satisfied with the form and content

of health services offered (improved health status and client

satisfaction), and that the benefits of publicly-funded health

care are equitably distributed (improved equity of access to

care).

• These health sector reforms varied in social, economic and

political environments, as well as in development stages of

health care systems.

HSR Components

• HSR deals with

– Equity

– Effectiveness

– Efficiency

– Quality

– Sustainability

– Defining priorities

– Refining the policies

– Reforming institutions for policy implementations.

Types of Reforms

o Changes in financing methods

o Changes in health system organization and

Management

o Public sector reforms

(Reforms Thomason Jane A, Health Sector Reform in Developing Countries :A Reality Check http://www.sph.uq.edu.au/acithn/conf97/papers97/thomason.htm Site last assessed on September 25, 2014)

Problem Definition

Diagnosis

Implementation

Policy Development

Political Decision

Evaluation

Health-Reform Cycle

POLITICS

ETHICS

(Getting Health Reform Right.Roberts, Hsiao, Berman, Reich,2004)

Challenges to reforms

• Unclear who has the power and responsibility.

• The minister for health?

• The medical association?

• The health insurers?

• The citizens?

• Power divided among groups - interests ?

• Doctors want more freedom and more resources

• Health insurers want more control and less spending

• Ministers want quick changes

• Public health specialists’ focus is health promotion

Health Sector Reforms In Developing Countries

HSR in China

• Economic changes began in 1978

• Rapidly dismantled the socialized mechanism of financing the healthcare

• Sudden introduction of market forces in previously state organized system

• Primary level services lost their collective funding base in much of rural china

• State budget were inadequate to support urban hospitals

HSR in China

• These changes unleashed a variety of subsequent changes. They were

Privatization of village doctor practices

Introduction of financial autonomy for hospitals

Cost escalation, as prices were liberalized and providers were free to increase revenues.

HSR in Africa

• African countries faced major financial crisis in 1980s and early 1990s

• Major programs of structural adjustments led by international financial institutions i.e. World Bank And IMF included

Allowing local currencies to be devaluated

Reducing govt expenditures(including social expenditure) and debt

Cutting back on civil service

HSR in Africa

• Zambian reforms initiated in 1991-92 included an innovative institutional restructuring of govt health care

• Created a Central Board of Health to oversee health care delivery matters external to Ministry of Health

• Also involved significant decentralization to district health management teams and health boards

• Introduction of user fees

• Development of nationally defined benefit packages

Origin of Reforms in India

Need for Reforms

Fiscal Constraints Poor social indicators

Need for reforms

Òil ShockEconomic crisis of 70s and 80s

‘Investing in Health’ WDR, 1993

‘Financing Health Services in Developing Countries’WB, 1987

(Health Sector Reforms in India, Initiatives from nine states. GOI. Vol 1. Aug 2004)

Fiscal Constraints

Economy committed to socialism

• Planned economic development

• Strong import substitution

Economic crisis

• No Balance of Payment Crisis

• Slack in foreign exchange flow

Oil Crisis

• Import dependent growth strategy

• BOP crisis post gulf war

19-04-2015

Fiscal deficit – Had to go for WB loan under the Structural Adjustment Programme

(www.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html)

Need for Reforms

o Financing Health Services in Developing Countries, World Bank, 1987

o User fee

o Insurance or other risk coverage

o Effective use of non government resources

o Decentralization

o Investing in Health, WDR, 1993

o Fostering an ideal environment

o Increased Govt. spending

o Promoting diversity and competition

(Health Sector Reforms in India, Initiatives from nine states. GOI. Vol 1. Aug 2004)

Privatization

• Regulating Private Health Care in India

•

• - COPRA 1986 - Pharmacy Act

• - IMC Act - Nursing Home Act

• - Code of ethics - Bureau of Indian Standard

• - Drugs & Cosmetic Act - Public Nuances Act

• - Dangerous Drug Act

• - Drug Price Control Act

Regulating the private health care sector: the case of the Indian Consumer Protection Act Health policy and planning; 11(3): 265-279

19-04-2015 23/49

Financing of Healthcare

Financing of Health Care

17

19

88

122

207

40

81

101

193

116

0 100 200 300 400

Bangladesh

India

Sri Lanka

China

Thailand

Public Spending

Private Spending

Per Person Total Expenditure in Health, PPP $(2005)

Financing health care for all: challenges and opportunities A K Shiva Kumar, Lincoln C Chen, Mita Choudhury, ShibanGanju, Vijay Mahajan, Amarjeet Sinha, Abhijit Sen. The Lancet 2011

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o 10 % of households – medical insurance 1

o Ailments that went untreatedoRural 28%

oUrban 20%

o Slow increase in insurance • ( National Commission for Enterprises in the Unorganized Sector )

o93% population in unorganized sector

o77% population - poor and vulnerable

o CBHI – very few studies, little information on impact 2

Financial Protection

1. NFHS 3 2. The landscape of community health insurance in India: An overview based on 10 case studies.

Devadasanad et al Volume 78, Issue 2, Pages 224-234 (October 2006)

http://www.healthpolicyjrnl.com/issues?Vol=78

http://www.healthpolicyjrnl.com/issues/contents?issue_key=S0168-8510(06)X0214-2


S.no Efficiency of Health Spending Rural (%) Urban (%)

1 Not satisfied by govt doctor or facility 41 45

2 Large distance 21 14

3 Non availibility of services / facilities 30 26

4 Private providers for OPD care 78 81

5 Private providers for in patient care 58 62

• Proportion of Respondents Quoting Poor Efficiency

• High cost of care


19-04-2015

Demise of Alma Ata Declaration

Failure of PHC 1

Replaced by HSR 1

Poverty trap 2

• Cut in soft sector budget

• Inefficient allocation

• based on market forces

• Most OOP in India for primary care through pvt

Health inequity

1. Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries John J Hall and Richard Taylor2. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Margaret Whitehead, Göran Dahlgren, Timothy Evans

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The Poverty Trap

Characteristics of the poor

Poor utilization

Unhealthy practices

Poor health outcomes

Ill health

Malnutrition

High fertility

Diminished income

Loss of wages

Catastrophic OOP

Poor health provision

Lack of income knowledge

Excluded from health finance system

Bad environment

(Poverty and health sector inequalities. Adam Wagstaff )19-04-2015 29

Health Sector Reforms in India

HSR IN INDIA

• Health sector reforms have come center stage since 1980s essentially

from frustration of the citizens in receiving any semblance of health

care from the public system. By 1990s the process had taken concrete

shape.

• In India, the health sector reforms broadly cover the following areas :

– Re organisation and restructuring of existing health care system

– Involving Community in health service delivery

– Health Management Information System

– Quality of care

All aspects of the sector from manpower to infrastructure to logistics to

monitoring to participation of stakeholders are subject matter of this process

EIGHTH FIVE YEAR PLAN (1992-97)

• Concept of free medical care was revoked

• Levying user charges for people above poverty line for

diagnostic and curative services.

• Ensured commitment for free / highly subsidized care for the

needy / BPL population.

• Promote social welfare measures like improved healthcare,

sanitation

• Check the population growth by creating mass awareness

programs

• Private sector promotion

NINTH FIVE YEAR PLAN (1997 - 02)

• Convergence and increase involvement of public, private

and voluntary health care providers.

• Enabling Panchayat Raj Institutions (PRI) in planning and

monitoring health programmes.

• Emphasis on basic infrastructural facilities including safe

drinking water and primary health care.

• Inter-sectoral coordination and utilization of local &

community resources.

• Greater emphasis on accountability

TENTH FIVE YEAR PLAN (2002 - 07)

• Reforms focused on primary, secondary & tertiary health

care level.

• Emphasis was on equity and financing health care

• Social Health Insurance for BPL population – Universal

Health Insurance Scheme.

• Human resource development

• Capacity building

• Quality assurance

• PRI empowerment

• Focus on public private partnership

Policy Shifts in Five Year Plans

8th

• Free medical care revoked

• Encouraged initiatives with private sector

9th

• Profit/non-profit NGO in health care

• Inter sectoral coordination of health programmes

• PRI in planning and monitoring

10th• Address issue of equity

(Adjustment and Health Sector Reforms: the Solution to Low Public Spending on Health Care in India? DelampadyNarayanawww.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html)

NATIONAL RURAL HEALTH MISSION

• Health care is now one of the thrust areas for the

Government of India.

• The Government mandates an increase in expenditure in

health sector, with main focus on Primary Health Care from

current level of 0.9% of GDP to 2-3% of GDP over the next

five years.

• The National Rural Health Mission (NRHM) which is the

main vehicle for giving effect to the above mandate was

launched in April 2005.


• NRHM is an overarching umbrella initiative which

subsumes the existing programmes of Health and Family

Welfare and seeks to be the omnibus vehicle for sector wide

reforms in India.

• The NRHM (2005-2012) in recognition of the needs of the

urban poor population has constituted a task force on urban

health to recommend strategies for improving health of the

urban poor.

The National Urban Renewal Mission (NURM) launched by the

Government of India in 2005 has a sub-mission on basic services

for the urban poor covering sixty cities in India.


• Architectural corrections in delivery systems in reforms

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)

ELEVENTH FIVE YEAR PLAN (2007-12)

• To achieve good health for people, especially for the poor

and the underprivileged

• Time-Bound Goals for the Eleventh Five Year Plan

– Reducing MMR to 100 per 100,000 live births.

– Reducing IMR to 28 per 1000 live births.

– Reducing Total Fertility Rate (TFR) to 2.1.

– Providing clean drinking water for all by 2009 and ensuring no

slip-backs.

– Reducing malnutrition among children of age group 0–3 to half

– Reducing anaemia among women and girls by 50%.

– Raising the sex ratio for age group 0–6 to 935 by 2011–12 and 950

by 2016–17.

HSR: AREAS

• Decentralization

• Human Resources

• Financial reforms

• Reorganization and restructuring of the existing health system

• Health Management Information Systems

• Communitization

• Quality assurance

• Convergence

• Public Private Partnership

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

HUMAN RESOURCES

• IPHS norms

– 2 ANMs/sub-center and 1 male MPW.

– 3 nurses/ANMs per PHC, 2 MO

– 9 nurses/CHC plus 5 specialists & 3 to 4 MO

– AYUSH staff

• Expanding available skilled human resource

• More medical UG & PG seats in govt. & private medical

colleges

• Reviving ANM and MPW training centers

HUMAN RESOURCES

• Compulsory rural postings

• Contractual appointments

• Incentives for difficult areas

• ‘Pooling’ of medical officers

• Multi skilling option for existing staffs

FINANCIAL REFORMS

• “We are now aspiring to taking the total allocation for the

health sector to 2-3 per cent of our GDP in the 12th (Five

Year) Plan period” : Mr. Ghulam Nabi Azad (union Health and Family Welfare Minister) at Pune (8th May 2011)

• New financing mechanisms of untied funds, breaking the

traditional Treasury route

• Untied grants to village, subcenters, PHC, block, district

FINANCIAL REFORMS

• Alternative financing of health care, such as

– user fees/charges,

– community finance,

– health cards or voucher systems,

– contracting services,

– social insurance schemes and

– private insurance

FINANCIAL REFORMS

• Demand side financing 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.

STRUCTURAL RE-ORGANIZATION

• Creation of Societies- bypass regular government

Procedure

• National/ State level technical support organization

like– NIHFW, SIHFW, NHSRC, SHSRC (State

Health Systems Resource Centre)

• Emergency response systems- 108 or 102

• Emergency Management and Research Institute

(EMRI)

STRUCTURAL RE-ORGANIZATION

• Procurement initiatives – TNMSC (Tamil Nadu

Medical Services Corporation ), KMSC, PHSC

(Punjab Health Systems Corporation) etc.

• National HMIS

• Meaningful partnerships with the non-governmental

providers for reaching quality health care

• Co location of AYUSH in PHCs/CHCs/District

Hospitals

COMMUNITIZATION

• Community accountability through RKS/ RMRS

(Rajasthan Medicare Relief Societies)

• monitoring process by community stakeholders

• Community Health volunteer – ASHA

• PRI involvement in health care

• Village health & nutrition days (VHND)

Quality Assurance

• New standards for government facilities

• IPHS

• NABH standards (National Accreditation Board for

Hospitals & Health care providers) &

• NABL standards (National Accreditation Board for Testing

and Calibration Laboratories)

• Focus on service guarantees

CONVERGENCE

• Envisaged horizontal and vertical linkages within

Health sector

• Intrasectoral and Intersectoral integration

• Mainstreaming of AYUSH

PUBLIC PRIVATE PARTNERSHIP

• Involving the private sector in service provision

• Private sector should be seen as a national asset and

alternate service delivery systems e.g. social franchising

should be considered.

• Outsourcing of services

• Contracting-in options –

– Specialists (Haryana, MP, Rajasthan etc.)

• Contracting-out options –

– Karuna trust in Karnataka, Punjab (village level

dispensaries)

Newer High-Potential HSR Initiatives

Government

initiatives

Purpose Issue(s) addressed

Telemedindia Combines information and

communication technologies(ICT)

with Medical Science for clinical

records, diagnostic tests, video

consultations and medical

education(several govt and private

healthcare network established)

To increase healthcare

services and education to

rural(and remote) parts or

under emergency

conditions

Compulsory

licensing

Grant non- patent holder(s)

permission to manufacture

patented drugs not available at an

affordable price (first grant to

cancer drug Nexavar in March

2012)

To increase accessIbility to

medications

Bachelor of Rural

Health

Care(BRHC)

A 3 &1/2 year rural health care course( proposed inn RajyaSabha)

To increase rural healthcare professionals

Newer High Potential HSR Initiatives

Govt initiative Purpose Issue(s) addressed

National Programme for Healthcare of the Elderly(NPHCE)

To be test –launched in 100

districts of the country in

2012-17

To reduce the incidence of

non-communicable diseases

(NCDs)in elderly

National programme for

Prevention and Control of

Cancer, Diabetes,

Cardiovascular Diseases

and Stroke(NPCDCS)

To be test-launched in 100 districts of the country in 2012-17

To reduce the incidence of

major non-communicable

diseases through lifestyle

modifications

Free Medicines for All Rs 28,560 crore plan to

provide 348 medicines for all

and must-prescribe generic

drugs mandate to doctors

(proposed 2012-2017

To increase accessibility to

medications

Healthcare for All by 2020 All residents will have

healthcare coverage via a

combination of public,

employer and private sources

To uphold the fundamental

right of all citizens to

adequate health care

WHO'S ROLE

• The World Health Organization, through its various

collaborative programmes at all levels, is involved in

capacity building in the member Countries to take care of

the evolving reforms in the health sector, mainly in the areas

of planning and human resources.

• To support the reforms processes in countries, a series of

publications, both at regional and global levels, have been

issued.

WHO'S ROLE

• An international "Forum on health sector reforms" has been

established to share and disseminate information on the

scope and nature of WHO's current and planned activities in

support of health sector reforms and in identifying priority

issues, reviewing country experiences and also the

approaches of different agencies in the field.

• WHO is also supporting institutional strengthening to

promote expertise in the developing countries.

Way Forward for effective HSR

Effective HSR

Incentive system to

states

Taxation

Regulation of pvtsector

Risk pooling

Strengthening of HMIS, Social audits, Community

monitoring, Capacity building, Prioritization,

Cost effective policy

Increased public

spending on health


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CONCLUSION AND POINTS FOR

CONSIDERATION

• Reforms encompass a range of purposeful efforts to change

the system for improving its performance

• You should make deliberate efforts, and conscious choices

so that the changes in the system would lead to the

improved performance in line with the desired goals.

• reforms have to be rational, logical and specific.


CONSIDERATION

• Health sector reforms is a political process.

• Radical reforms is impossible without robust political

leadership, informed by sound technical advice.

• reforms should take place as a sustained process of

fundamental change in health policy and health institutional

arrangements.


CONSIDERATION

• Improvements in the functioning of the public sector and

civil service systems in general will occur in parallel with,

and sometimes in response to, other aspects of institutional

reforms, such as increasing privatization.

• Sustained information and education are needed to generate

wider political and public understanding and support.

• Health system research and other forms of research studies

will provide evidences to strengthen the processes and

mechanisms for health sector reforms.


CONSIDERATION

• Health sector reforms demand an explicit link between

researchers, planners and decision-makers for the optimal

use of research findings.

• While every reforms experience is country specific, there are

always important lessons to learn from comparing options,

identifying common issues addressed and the tools used, and

evaluating effects of various reforms initiatives.

Health Sector Reforms prersentation

Healthcare

Transcript of Health Sector Reforms prersentation