A Policy Analysis of the Health Sector Reform Process in India

1
A Policy Analysis of the Health Sector Reform
Process in India

• Dr. Rama Baru
• Associate Professor, JNU
• India Habitat Center, March 7th, 2003

2
A policy analysis of the HSR process in India

• The overall objective of this study is to
  explore the perceptions and experiences of health
  sector reform at the national level
• It specifically explores the definition, content,
  process, and sustainability of the health sector
  reform process in India.
• It seeks to understand both the internal and
  external forces that are shaping the health
  sector reform process.

3
Definition of Health Sector Reform

• The definition of health sector reform used in
  this study is that it is a fundamental rather
  than an incremental change, which is sustained
  rather than one-off, and purposive in nature
  (Cassels1997).
• According to Cassels (1997) health sector reform
  includes
• Improving the performance of civil service
• Decentralisation of power and resources
• Improving function of national health ministries
• Broadening health financing mechanisms
• Introducing managed competition
• Privatization
• introducing managed competition between public
  and private sectors

4
Data Source Interviews
5
Motivation for the Analyses of Health Sector
Reforms

• Health Sector reforms are bound to influence the
  provisioning, financing, manpower, drugs and
  technology in the health service system
• Reforms will have a bearing on the effectiveness
  of National Health Programmes.
• Reforms will also have an impact on the
  availability, accessibility, quality and cost of
  health services-both general and specifically for
  reproductive and child health

6
Questions Pursued in the Analyses

• Varying definitions of health sector reform
  -Indian government and major donor agencies
• Motivation for reforms of different donor
  agencies and the government
• Content of health sector reforms
• Implications of HSR for health services delivery
• Sustainability of the reform process
• Implications for equity

7
Methodology

• All who were involved in the health sector
  reform process were contacted and key persons
  were interviewed from the major multilateral and
  bilateral agencies and the Ministry of health and
  family welfare. The donor agencies included The
  World Bank, DFID, SIDA, and the European
  Commission

8
Methodology

• Elements of HSR that got special emphasis during
  the nineties with loans/grants from multilateral
  and bilateral agencies were reviewed
• Loans to communicable disease control programmes
  with focus on specific diseases viz.
  tuberculosis, malaria and HIV/AIDs
• Loans for the Reproductive and Child Health
  programme
• Loans to state governments for the state health
  systems projects for primary, secondary and
  tertiary levels

9
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).
• During negotiating for the loans, the Bank told
  us that unless we accepted conditionalities for
  power reform they would not give us loans for
  health. We told them that we did not want to be
  tied down by such conditionalities and would
  rather not get the loan. Then they came back to
  negotiate with us on the terms set by us.
  (Interview with senior official in the health
  ministry, Delhi, March 2002)

10
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 programme 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). .

11
Plurality of definitions

• The European Commission on the other hand argues
  that 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)

12
Plurality of definitions

• Some academics and researchers (based on recent
  studies) on health sector reforms regard them as
  largely driven by the World Bank, though accepted
  by the national government in order to get loans
  to overcome the fiscal crisis, without a
  corresponding vision of the national government.
  
• Some academics have pointed that it is the lack
  of a vision of health sector reform within the
  ministry that results in the identification of
  HSR with donor led initiatives (Interview with a
  senior health researcher, Chennai, April,2002).

13
Space for negotiation

• According to the European Commission the
  government does have space for negotiations in
  terms of the programme content and the choice of
  technology. Space defined by vision, technical
  intellectual capacity of government officials and
  political will of state governments For example,
  user fees in Kerala and AP.
• The role of the bureaucrats has been a mixed
  picture with those who have a vision, some
  who collude with foreign agencies and others
  who want to pursue their own pet ideas (
  Interview with Senior Official of the European
  Commission, Delhi, March 2002)

14
Space for negotiation

• The bureaucrats from the health ministry opined
  that even though the World Bank was the major
  actor it did not determine the priorities for the
  country since the quantum of funding is small and
  not an additionality to the existing budget.
• Although the outlay is insignificant, a senior
  bureaucrat in the health ministry argued that,
  we negotiated with the World Bank based on our
  needs. There was no element in the disease
  control programme that was seen as unnecessary
  by the Indian government. (March, 2002) The
  only programme that was pushed by the World
  Bank was for HIV/AIDS but the other disease
  control programmes namely tuberculosis and
  malaria were seen as important internally and
  were endorsed by the Indian technocrats
  themselves. (ibid).

15
Space for Negotiation

•  At the state and central levels the push
  factor for taking loans is the fiscal crunch
  faced by the states. Given the poor state of
  finances, the state governments opt for loans and
  see it as a way of tiding over a financial
  crisis.

16
World Banks Review of the Health System Reform
Project

• The Banks image of itself as a provider of
  hardware and infrastructure rather than a
  developer of human resources.
• Resistance from Indian counterparts to address
  systemic issues.
• Shortages of resources and effective managers.
• Focus on the public sector and on expanding the
  public health system
• Application of a single model to areas with very
  different characteristics.

17
Ownership of Reforms

• The process of reform has been a top down with
  very little involvement from the community. The
  plans are made at the central and state levels
  with very little input from the communitys
  needs.
• As a result the ownership of reforms at the
  state and lower levels has been weak.
• Capacity weak at the state, districts levels
• Resistance of public sector doctors to give
  administrative powers to Panchayats
• Governance of public institutions unaddressed

18
Implications for equity in access and utilization

• Privatization
• Corruption
• Rising cost of care, increasing cost of drugs,
  user fees

19
Sustainability of Reforms

• Most state governments are not in a position to
  increase allocations
• In addition to sustaining these programmes, the
  states will have to also pay back the loans,
  which will only increase their financial burden.
  
• Frequent transfers of bureaucrats and technocrats
  as negatively affect the implementation of the
  reforms.
• Lack of civil service reforms
• Corruption within the health services as an
  additional impediment to sustainability of
  reforms
• Need for more effective donor coordination

20
Major Issues

• Definitionincremental not fundamental
• The project approach to health sector reform
• spaces are available for negotiations at both the
  central and state levels with multilateral
  agencies.
• 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 interviews suggest that the entire reform
  process is a top-down approach. There is
  little consultation with the personnel at
  different levels of the health

21
Major Issues

• 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.
• In the RCH programme the government has adopted
  the Rights Based Approach after ICPD but this
  has not been effectively transferred to the
  different levels of providers.
• New budget?