Devaki Nambiar PhD, Kabir Sheikh MBBS MPH PhD Health Governance Hub Public Health Foundation of India 4 th Technical Review Meeting for the HPHFKH 10 th October 2011

A team of researchers across our family of institutions in five cities Core interest in the relationship between health systems governance and social justice THEME AREAS Regulation and stewardship Community action for health Health workforce governance Pharmaceutical policy Urban health governance Public health philanthropy As India moves towards Universal Health Coverage…

Sheikh, Saligram, Prasad ( ) Funding: Nossal Institute

Normative position: Regulation as a means to health equity, health rights, development (Mackintosh 2007) Approach: Backward Mapping: ‘bottom up’ understanding of field level phenomena generate policy needs (Elmore 1982) Process: Quality of care Accessibility of care Conduct of providers Costs of care for users Regulatory targets identified from in- depth literature review on LMIC ‘mixed’ health systems (Oxfam 2009, Nishtar 2010 ) Development of tool for policy mapping and gap analysis of policy design (relative to target) and implementation (relative to design) Pilot study in two states in India MP Delhi

Madhya Pradesh (MP) Cost of CareRSBY and government subsidies to private hospitals both aimed at reducing costs of private care for EWS Do not address the high incident costs in public facilities, or financial protection of non-EWS. No direct control of care costs, no regulation of competition. No known laws or regulatory policies for the curtailment of costs for users of health care, other than recently introduced Janani Sahayogi Yojana (Mothers’ Assistance Scheme) Quality of Care No credible regulatory mechanism to limit practice by unqualified providers. Absence of credible community-based forum for grievance redress. Conduct of Providers Accessibility of Care Not addressed through act or policyVariable workforce distribution, only mandatory rural service, no incentive based policies

DelhiMadhya Pradesh (MP) Cost of CareInformation asymmetries impede uptake of social insurance scheme, also lack of stringent regulatory component. Reduced investment in regulatory capacity of relevant departments impedes enforcement of EWS free-bed condition for hospital subsidy Clinical Establishments Act, PNDT, MTP: Implementation is partial due to personnel constraints problems of inter-departmental coordination, affects relationships with hospital owners Quality of Care Multiple contestations of NHRA have diluted content. Partial implementation due to personnel constraints and organizational inertia, active resistance of medical fraternity Self-regulatory council’s commitment to disciplinary functions, made problematic by closeness to associations who oppose regulation. Engagement with additional tasks such as reducing quackery greater than performance of disciplinary roles. Conduct of Providers Councils role less disciplinary, more advocacy for professionals’ rights, medical sanctity Accessibility of Care Health authority subordinated to urban development authority in determining location of new hospitals Implementation of rural medical bonds hampered by extensive contestation by doctors’ groups, problems in coordination between government departments involved in placements

Sheikh, Gilson, Bennett, others (2011) Commissioned by PLoS Medicine

SYSTEMS FUNCTIONS  Systems defined on basis of their utility, problems mainly relate to efficiency  Decisions are concentrated, flow in one direction  Policy content not problematized E.g. WHO ‘building blocks’ Systems Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems Outputs Outcomes Policy Decisions

Systems ‘Software’ Ideas and interests, Relationships and power, Values and norms Systems ‘Hardware’ Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems International National Subnational Local ARENA COMPLEX AND SOCIALLY CONSTRUCTED  Decisions are diffused, relationships are non-linear  ‘Software’ critical to health systems performance  Problems (and solutions) are related to (understanding) complexity  Shaped by particular politics, culture, discourse (and not others)  Solutions within and beyond health systems (e.g. Frenk 1994, de Savigny and Adam 2009, Lambert 2006, Illich 1970)

Thank