State Institute of Health and Family Welfare, Rajasthan, Jaipur Health Sector Reforms Shiv Chandra Mathur Director State Institute of Health and Family Welfare, Rajasthan, Jaipur Shiv Chandra Mathur is a public health specialist working for developing human resources for health. His current assignment involves him consistently in organizing in-service trainings for health professionals. Present paper is a conceptual analysis of the epidemiological transition occurring in the developing world with particular reference to India. Viewers/Readers are welcome to share their observations/comments with author at shiv_mathur@hotmail.com. They may go through other lectures from the author in supercourse series on RCH, adolescent health, population policy, NRHM and violence against women in India www.pitt.edu/~super1  (through topic, keywords, lecturers.... pages) The current lecture is addressed to health professionals of India in particular, large number of whom in different states of India are involved in introducing and implementing health sector reforms in the public systems. Shiv Chandra Mathur/03.03.2005

Challenges to the Health System Stagnant public spending on health Between 75-90% spending by states. Largely tied up in salaries expenditures Curative public services favor the rich Hospitalization frequently means financial catastrophe. One of the major challenge to the reform process is to perceive the macroeconomics of investments in health in a right perspective. Shiv Chandra Mathur/03.03.2005

WDR 1993 - Approaches Fostering environment enabling households to improve health; Improving Government spending on Health; Promoting diversity and competition. Whole process of reform started with implementing the recommendations of World Bank report on Investing in Health released in 1993. Three major recommendations of this report are highlighted here. Shiv Chandra Mathur/03.03.2005

Health Sector Reforms What do we mean by reforms? What are the essential components of reforms? How do reform differ from Normal evolutionary system changes? Subsequent slides will now deal with these three major questions. Shiv Chandra Mathur/03.03.2005

Health Sector Reforms definitions Sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector. Berman,1995 A process that seeks changes in health sector policies, financing, and organization of services, as well as the role of government, to reach national health objectives. Population Council,1998 Shiv Chandra Mathur/03.03.2005

HSR is concerned with Defining priorities Refining policies Reforming Institutions Shiv Chandra Mathur/03.03.2005

HSR deals with Equity Efficiency Quality Financing Shiv Chandra Mathur/03.03.2005

Principles of Health Sector Reforms *Overseeing the needs of the entire population – pro-poor; gender sensitive and client friendly. *Looking forward to the health transition *Removing the blind spot to the private sector *Focusing efforts – by ensuring quality, efficiency and accountability of health services Shiv Chandra Mathur/03.03.2005

Functions covered by HSR Governance Provisions Financing Resource Generation Shiv Chandra Mathur/03.03.2005

Key elements of HSR Structural rather than incremental/evolutionary change; Change in policy objectives followed by institutional change, rather than redefinition of objectives alone; Purposive rather than haphazard change; Sustained and long term rather than one off change; Political top down process led by national, regional or local government. Shiv Chandra Mathur/03.03.2005

Governance related HSR Evolving standard protocols for care at P/S/T care settings Quality assurance mechanism such as Consumer Protection Act and Citizens charter for hospitals; Appropriate delegation of power to PRI’s. Shiv Chandra Mathur/03.03.2005

Classifying HSR- financing User Charges Insurance Private sector Growth Increasing resources to health sector Shiv Chandra Mathur/03.03.2005

Classifying HSR- health system organization and management Decentralization; Contracting out of services; Reviewing the public-private mix. Shiv Chandra Mathur/03.03.2005

Classifying HSR - Public Sector Reforms Downsizing the public sector; Productivity Improvement; Improving geographic coverage; Increasing role of local government. Shiv Chandra Mathur/03.03.2005

Reforms attempted in Health and F.W.Sector in Rajasthan Jan Mangal Project 1992 Strengthening FRU’s 1994-2001 Decentralized District Planning since 1995-96 Creation of RMRS-user charges since 1995-96 Reorganizing the Training System 1995-96 Concurrent Evaluation in F.W.Program 1996-97 Here is an example of Health Sector Reforms efforts made in an Indian state over aperiod of 1½ decade. They range from introducing a community based contraceptive distribution project to creating autonomous societies in a large number of hospitals. Shiv Chandra Mathur/03.03.2005

Reforms attempted in Health and F.W.Sector in Rajasthan - 2 Draft Training Policy 1997-98 Devolution of Powers to PRI’s - 90’s Population Policy 2000 Job Responsibilities specifications 2000 Preparation of EDL 2000 Health Vision Document 2025 Change introduced through reform process certainly changed the quality of health care services delivery but rising expectations of the community diluted the perception of change. Shiv Chandra Mathur/03.03.2005