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Health sector reform: Scope and framework for assessment


Reforms in the health sector have been happening for a long time, since post ... to market economies, e.g. China, Vietnam and countries of erstwhile Soviet Bloc ... – PowerPoint PPT presentation

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Title: Health sector reform: Scope and framework for assessment

Health sector reform Scope and framework for
  • TK Sundari Ravindran
  • 6 February 2007

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
  • 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.

  • At least three scenarios in which HSR was
  • 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
  • As part of Structural adjustment programmes by
    countries facing a severe resource crunch Many
    Asian and African countries, and the most common

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

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
  • Organisational Changes (e.g. decentralisation,
    changing the public-private mix)

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

HSR in India
  • World Bank Major driver of HSR but joined also
    by EU and other bilateral donors over the last 15
  • 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.

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
  • 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,

HSR in India-3
  • Some variation by state in the details of the
    HSDP, but overall objectives remain the same,
  • Increasing access, especially for vulnerable
    population groups (poor and SC/ST always
    included women mentioned in some and not others)
  • Improving quality
  • Improving efficiency

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
  • Investment in pharmaceutical and bio tech
    industries for research

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

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

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
  • 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

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,

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
  • 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,

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
  • 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?

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?

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?

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
  • Initiation of services for populations not
    hitherto covered? (e.g. adolescents, menopausal

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)