1. 31 st Annual Conference Indian Association of Preventive and Social Medicine Health Sector Reforms:Relevance for India 27 th February 2004 Dr. Dinesh Agarwal, M.D., Technical advisor (Reproductive Health) UNITED NATIONS POPULATION FUND, INDIA

2. Scope of Presentation  Health Sector in India and Characteristics  Health System Outcomes: Ultimate and Intermediate  What are reforms?  Do we need reforms in Health Sector?  Building A Reforms Agenda for India  Conclusions

3. Health System in India : Composition  Treatment providers Different pathies, Formal and informal Wide settings  Preventive and Promotive Care Immunization, Family Planning  Financing mechanisms Governments, Out of pocket,Insurance Contd……

4. Health System in India : Constituents  Input Producers Medical,Nurs.colleges Pharma, diagnostic Instruments  Planner and Health Managers PEOPLE, INSTITUTIONS AND ACTORS WHO WORK FOR HEALTH

5. Health System in India : Characteristics  Vast and Complex: Multiple Planners and number of providers  21% of Global burden of Diseases (16% population)  25% of all Maternal Deaths Contd……

6. Health System in India : Characteristics  Conflicts : Patient Care, Training and Research  Politics Influences: Goals, Priorities and Strategies: Variations in Commitment  Evolution of Health System reflect culture, history and norms

7. Goals of Health System 1.Health Status of Population  Life Expectancy  DALYs lost  Morbidity and Mortality rates Contd……

8. Goal of Health Systems 2. Customer Satisfaction/Systems responsiveness  Client Satisfaction (NFHS)  May depend on non-clinical aspects of care  Difficulty in measurement Contd……

9. Goal of Health Systems 3. Financial Risk Protection  Are People protected against high cost of medical care?  Catastrophic Illnesses – Poor People

10. How are we doing ?  Improved Life Expectancy:Yet averages mask equity perspectives ( Class, regional &gender) (49 years in 1970 to 63 years in 1998)  High mortality and burden of diseases among poor: IMR,Diarrhea Diseases etc  Client Satisfaction: “High” level in large scale data sets Health Sector most corrupt (Transparency International) Contd……

11. How are we doing ?  Overall Government spending 0.9% GDP – Bottom quintile in world( WHO 2001)  Private Expenditures: 80% of all spending on health  Nearly 40% of hospitalized in 1995-96 fell into debt.  Large Scale Inter-State Variations: Risk of falling in debt after hospitalization (17% in Kerala – Double in UP/Bihar) Ref: Mehal et al 2001

12. Delivery of Public Health Services: Who uses?? 1.Richest quintile consumes 3 times more public health resources as compared to poor 2.Most States reflect “Pro-rich” distribution 3.Health needs of urban poor, marginalized and Tribal population

13. Intermediate Outcomes of Health Systems  Efficiency  Quality  Access  Financial Burden These are widely discussed characteristics of Health system performance These are means to an end Source: GHRR-HSPH, 2003

14. Efficiency Using resources in the best possible manner to achieve goals  Technical Efficiency: How do we produce Output/s?  Allocative Efficiency: What we produce?  While TE is essence of management, AE is more linked to political economy of health Example: Maternal Mortality in India

15. Quality Degree to which goods and services perform as desired  Several Definitions,framework and approaches  No term is health systems more abused  Multiple players-Management,Insurance comp. providers,Clients and Community  Causality important-Influences both health status/Satisfaction–widely discussed  Clinical and Service quality dimension  Different budgets give different quality!!

16. Quality of Health Care in India  Public/Private Systems Hospital Care Quality: ALOs Ambulatory Care: Multiple Visits Preventive and Promotive  Use of Clinical Care protocols, guidelines  Quality of equipments, supplies and Medicines  Service Quality Issues: Privacy Confidentiality Amenities HIGHLY VARIABLE: WORLD CLASS to THIRD CLASS

17. Access  Availability of Services  Effective Availability Socio-cultural Economic Distance  Utilisation (Marker of Demand) Ability of Clients to use services they wish to use!

18. Access : Example 1.Availability of women providers at SCs/Outreach 2.Are visits regular/predictable – “Up-down” Phenomena 3.Gender of providers, culturally appropriate:Jargon 4.Economic access – Opportunity Cost – Flexible payment 5. Utilisation – distance factor 6. What is the package of services? 7. Can poor women negotiate use of health services?? Womens access to Primary Reproductive Health Care Source: Gender Mainstreaming in RCH II – A Report

19. National Context for Reforms 1. Demographic Transition (Shift from high fertility/mortality to low mortality and fertility) 2.Epidemiological Transition( Disease Patterns) 3.Social Transition – High Expectations 4.Technological Transition – Rapid diagnostics, Therapeutic modalities 5.Health Systems performance problems widely Acknowledged 6.Demand for increasing allocation (NHP)

20. What do we mean by “HSR”? “Purposeful” efforts to change the system to improve its performance  Rational/logical  Specify goals  Use evidence based strategies  Limited “r”eforms: Small changes  Big bang “R”eforms: Sweeping changes Source: GHRR-HSPH, 2003

21. Reforms Agenda for India 1. Health Policy Process – Decentralization, devolution, delegation: “ONE SIZE DOES NOT FIT ALL” 2.Content: Comprehensive, Epidemiological Transition, Standards,private sector 3.Oversight function – Regulation (Clinical establishment, PNDT, HOT Acts) 4.Health Financing Options

22. Barriers to “Reforms” 1.Reforms are “Hard” Choices: Truly Difficult 2.Often consequences of actions are difficult to predict 3.Doing better for one goal may not necessarily lead to improvement in other goals 4.Resistance to “Change” “Status quoists” 5.Those who can benefit from reforms are not powerfully/less organised

23. THANKS