Health sector reform: Scope and framework for assessment

1
Health sector reform Scope and framework for
assessment

• TK Sundari Ravindran
• 6 February 2007

2
What do we mean by HSR?

• Reforms in the health sector have been happening
  for a long time, since post Second World War era
  in Europe, insurance reforms in East Asia and
  reforms in response to economic crises in 1980s
• Reforming the health sector is an ongoing
  process.
• HSR used as a noun to indicate the generation
  of reforms which came about since 1990s, with a
  thrust on containing the states role in health
  care provision and financing and promotion of the
  private sector.

3
Context

• At least three scenarios in which HSR was
  introduced
• Reforms following transition from socialist to
  market economies, e.g. China, Vietnam and
  countries of erstwhile Soviet Bloc
• Changes resulting from social movements to reform
  the state apparatus, e.g. many Latin American
  Countries
• As part of Structural adjustment programmes by
  countries facing a severe resource crunch Many
  Asian and African countries, and the most common
  context

4
HSR Professed objectives

• To address problems of
• Poor quality of care
• Inequities and limited access to health
  services
• Insufficient funding for health
• Inefficiencies in service delivery
• Lack of accountability and insufficient
  responsiveness to client need

5
Variations in nature of health sector reforms

• Different countries may institute reforms in
  different aspects of the health sector
• Changes in financing mechanisms (balance between
  tax revenue, social or private insurance, user
  fees, external aid sector-wide approaches etc)
• Changes in priority setting mechanisms (e.g role
  of the state in regulation and service provision
  basis for decisions about which services ought
  to be publicly funded, which regions or
  populations get priority)
• Changes in organizational mechanisms (management,
  integration of services, logistics and supply
  systems)
• Organisational Changes (e.g. decentralisation,
  changing the public-private mix)

6
Variations in scope of health sector reforms

• National vs. state or provincial levels
• in financing, organization and priority setting
  vs in one or two of these
• sector-wide versus programme-specific (MCH,
  communicable diseases)
• Big R reforms Changes in financing,
  priority-setting and organisational mechanisms
  affecting a substantial part of the health
  system e.g Zambia
• Small r reforms e.g. Introduction of user
  fees, public-private partnerships, hospital
  autonomy

7
HSR in India

• World Bank Major driver of HSR but joined also
  by EU and other bilateral donors over the last 15
  years.
• 1972-1988, WB funded five population projects.
  However, its role in setting policy was limited.
• WB funded the first free-standing health project
  in 1992. Currently, 5 specific disease-control
  projects and 9 Health Systems development
  Projects at state level AP, Karnataka, Punjab,
  West Bengal Orissa, Maharashtra UP, Tamil Nadu
  and Rajasthan.

8
HSR in India-2

• Deterioration in economic conditions in 1990-91
  following the first Gulf war, serious Balance of
  Payment crisis gt Central governments interest
  in seeking external assistance.
• Bank lending (for all sectors) linked to private
  sector development and deregulation of financial
  sector
• Serious fiscal crises in most states during the
  1990s even in previously well-managed states
  like Tamil Nadu, because of growth of salaries,
  subsidies, reduction in share of tax from Centre,
  debt servicing.
• No money for health sector, and declining share
  of centre.
• For the WB, state lending was of interest Bank
  can have more leverage than at the national
  level. State HSDPs provide opportunity to
  influence more fundamental determinants of the
  public health system. (Zanini G, World Bank,
  2002)

9
HSR in India-3

• Some variation by state in the details of the
  HSDP, but overall objectives remain the same,
  viz
• Increasing access, especially for vulnerable
  population groups (poor and SC/ST always
  included women mentioned in some and not others)
• Improving quality
• Improving efficiency

10
Country Assistance Strategy World Bank

• Increasing public health expenditure
• Decentralization of health services
• Public private partnerships in health
• Regulation of private health sector
• Promote Health insurance
• Focus on maternal, infant and child health
• Control of infectious diseases (TB, malaria,
  HIV/AIDS) and eradicate leprosy and polio
• Promote water and sanitation, with cost recovery
• Commercially market for clean household energy
  products
• Investment in pharmaceutical and bio tech
  industries for research

11
Other external actors

• European Commission Involved since 1998.
  Currently assisting 60 districts in 24 states and
  several urban centres
• Strategy SIP or Sector Investment Programme, a
  form of Sector Wide Approach (SWAp), involving
  preparation of District Action Plans (DAPs),
  Sector Reform Cells at the State level.
• DFID working with the Centre and in four states
  AP, MP, Orissa and West Bengal

12
Local push for reform

• There have been initiatives in individual states
  for reforming the health sector.
• These include reforms ensuing from political
  decentralisation financing reforms that were a
  part of economic liberalisation even before the
  state HSDP started, and reforms that have
  resulted from advocacy by civil society actors
  (e.g. Jan Swasthya Abhyan, Community Action Cell
  Karnataka)

13
11th approach plan and health

• a) National rural health mission
• Integrated district health systems (of different
  H. departments and sectors)
• Integration of allopathic and traditional
  medicine
• Devolution at GP level (sub centers)
• Public private partnerships in health
• b) Financing and delivery of health
• User fees
• Social health insurance
• Community based health insurance
• Contracting out immunization
• Entitlement system for women to have
  institutional delivery

14
The overall scenario

• Since nearly all state governments are facing a
  fiscal crisis and health is not a high priority
  area of investment, most of them have been
  applying for loans to the Bank.
• The entire reform process is a top-down
  approach. There is little consultation with the
  personnel at different levels of the health
• Reference Baru R. A Policy Analysis of the
  Health Sector Reform Process in India. New Delhi,
  2003.

15
The overall scenario

• There is very little co-ordination among donors
  on health sector reform. There are situations
  where two or three donors are operating in the
  same state with their own priorities and agendas.
  This has raised the problems of duplication and
  adhocism when it comes to programme
  implementation.
• Donor-led reforms co-exist with locally initiated
  reforms, and are not always headed towards the
  same goals.
• Reference Baru R. A Policy Analysis of the
  Health Sector Reform Process in India. New Delhi,
  2003.

16
Assessing reforms Equity

• In service delivery
• Has the reform increased access to services
  overall? (Increase in utilisation esp. of
  preventive services decrease in untreated
  morbidity avoidable mortality) In the public
  sector?
• How is the increase (or decrease) distributed
  across population subgroups (by caste, economic
  status, gender, age, rural/urban residence etc.)?
• How is the increase (or decrease) distributed
  across levels and types of services?

17
Assessing reforms Equity

• In financing
• What has been the consequence of reform for cost
  of health care? For affordability? Has
  expenditure on health as a proportion of
  consumption expenditure of households increased?
• How is the increase (or decrease) in health
  expenditure distributed across population
  subgroups (by caste, economic status, gender,
  age, rural/urban residence etc.)
• How is public expenditure on health shared across
  population subgroups?

18
Assessing Reforms Quality, efficiency

• Has the reform improved quality of care in health
  services? Which services? Which population
  subgroups have benefited most, and who the least?
  
• Has the reform improved efficiency of health
  services? Which services? What levels?

19
Assessing the implications for SRH services

• Yard stick ICPD, ICPD5 commitments
• Some questions to ask
• Have reforms resulted in-
• Increase in the range of services available? (e.g
  RTIs/STIs, infertility services, cervical cancer
  care)
• Initiation of services for populations not
  hitherto covered? (e.g. adolescents, menopausal
  women)

20
Assessing the implications for SRH services-2

• Have reforms resulted in-
• Improvement in the quality of care?
• Increase in access to care for low-income and
  other marginalised groups?
• Elimination of cost barriers in accessing
  essential and emergency services (e.g. family
  planning abortion and delivery care EOC)