Health Sector Reforms

Outline:

• What is Health System?

• Health System Reform?

– Understanding the deeper meaning of health sector reform?

– Goals of HSR

• Historical Perspectives: Health Sector Reform

• Health System Reform in India:

Public Sector

Private Sector

• International Examples.

• Impact evaluation of Health Sector Reforms

What is Health System?

• A Complex issue.

• “All the activities whose primary purpose is to promote, restore or maintain health.”

WHO 2000

• Every country has a health system; • May be fragmented or however unsystematically it

operates.• So Does India?

Health Systems: 3 Fundamental Objectives

• Improving the health of the population they serve;

• Responding to people’s expectations;

• Providing financial protection against the costs of ill-health.

Why understanding the health system is complicated?

Complexity, Conflict, Social Context, Political

Health System Framework:

Health Sector Reform ?

Reform:•“A change for the better or an improvement”. •As verb: “to improve by alteration, correction of error, or removal of defects or to put into a better form or condition”Health system Reform:“Sustained purposeful change to improve the efficiency, equity and effectiveness of the health sector” Peter Berman, 1995.

“Defining Priorities, refining policies and reforming the institution through which the policies are implemented” Cassels, 1995

Health Sector Reform ?..........

“A sustained process of fundamental change in policy and institutional arrangements of the health sector, usually guided by the government. The process lays down a set of policy measures covering the four main core functions of the health system, viz. governance, provision, financing and resource generation. It is designed to improve the functioning and performance of the health sector and ultimately the health status of the people.”

WHO 2000

 Historical Perspective: Journey of Health Sector Reform?

• 1980s: Global economic crisis lead to changes in economic policies of several countries.

• 1987: The World Bank report “Financing health services in developing countries”.

• 1993: World development Report: “Investing in Health”.

• 1990s to 2000s: Poverty again gained the center stage and thus health came in focus due to close linkage between poverty and health.

Historical Perspective: India

• 1980s: Traces of economic liberalization but not significant.

• 1992: Economic liberalization took place. Health Sector Reform process started.

• Reform Process continued under Five Year Plans: Eighth five year plan: (1992 – 97): Ninth Five Year Plan: (1997-2002): Tenth Five Year Plan: (2002 -2007): Eleventh Five Year Plan: (2007-12):

Three Generations of Health System Reforms:

• The first generation:• Establishment of national health care systems, and • The extension of social insurance systems to middle

income nations

• The Second generation:• Promotion of primary health care

• The third generation:• The concept of universalism:

Understanding HSR deeply;

• William Hsiao (2000):• Specified a set of “control knobs”.• famously known as Hsiao’s Knob.• 6 such knobs:

Financing, Payment, Organization, Regulation, and Consumer behavior.

Key Concepts in the Definition:

• Fundamental:– The “Big R”: Involving 2 or more Hsiao’s Knob:

Example: Setting up national health insurance scheme. – The “Little R”: address only one control knob:

Example: Introduction of user charge in government hospitals.

Autonomy of national health institute.• Purposeful: Elements and components of the reform need to have

been developed in a rational manner• Sustainable: Most of the reform process are sustainable

Types of Health Sector Reform

1. Changes in financial system: Big R reform: Increasing resources to health sector,

Change in national health financing Small R reform: Introduction of new user fee, small

community financing schemes.

2. Changes in health system organizations and management:

Decentralization, Contracting out of service, Public private mix

3. Public sector reformIncreasing the role of local govt., Introduction of competition;,

The Health Sector Reform Cycle:Ethics politics

Problem Definitio

n

Policy Developme

nt Political decision

HSR Goal: Improve Health System Performance

• Access

• Equity

• Efficiency:

• Quality

• Sustainability

• Improved health status Across all services

Health Sector Reforms in India:

• Real-time Health Sector Reform started in early 1990s.• Economic liberalization.Eighth Five year plan: (1992 – 1997)• Process started.• Paradigm shift in thinking: focus shifted from vulnerable to

underprivileged group.• Introduction of user fee.• Major reforms in the health infrastructure:

• Strengthening of facilities• Provision of essential equipments• Filling up of all vacant posts• Ensuring supply of essential drugs, dressings and other material.

• Health management information system (HMIS):

• Need based target for health infrastructure: • Re-organization of the Indian Systems of Medicine and

Homoeopathy (ISM&H) dispensaries.• Health system research • Involvement of private sector. Support and accreditation of private

sector.• Family welfare:

• Holistic Approach: • Decentralized planning and implementation. • Target reduction in birth rate in place of couple protection rate

• Involvement of PRI in administration and implementations. • Voluntary organizations in a mass movement

9th Five year plan (1997 – 2002)

• Horizontal integration of vertical programmes.• Development of Disease Surveillance and Response

mechanism.• Health Impact Assessment.• Appropriate management systems for emergency, disaster,

accident & trauma care at all levels of health care. • Improved HMIS and logistics of supplies.• Involvement of voluntary, private organizations and self-help

groups.• Panchayati Raj Institutions (PRI) in planning and monitoring.

10th Five Year Plan (2002- 07)• Reforms at primary, secondary and tertiary level population. • Near universal coverage:

– For meeting the cost of hospitalization and continuous care for chronic disease.

– Health finance options:Health insurance for individuals and social insurance for

below poverty line (BPL) families.

•  Structural & Functional Reforms:– Human resource development– Integration of health and family welfare society at

state and district levels,– Effective system of disease surveillance and

response at district, state and national level.

• Financial Reforms / Resource related reforms:

• Governance related– Introduction of comprehensive regulations – Evolving standard protocols for care for various illnesses – Quality Assurance & redressal mechanism – Involvement of the Panchayati Raj Institutions (PRIs) in

planning, monitoring of ongoing programmes

• Participation (Public Private Partnership):– Private sector practitioners in the National Programmes.– AYUSH and ISM and H practitioners.– Contracting Private providers for RCH Services.– Contracting out the services

Reform under Tenth Plan: Cont...

National Health Programme

•Formation of District Level Societies

•Participation from the private / NGO sector

•Involvement of NGOs in the Family Welfare Programme:

Mother NGO (MNGO) Scheme and the service NGO (SNGO) scheme.•Involvement of bi-lateral & multi-lateral agencies in health sector reforms

•NRHM:

National Rural Health Mission

Reform or Not ?

NRHM: Paradigm Shift in Health System

11th Five Year Plan (2007 – 12):• Improving Health Equity.• System-centric approach than a disease-centric

approach.• Local enterprise for solving local health problems.• Further Decentralizing Governance.• Secondary and tertiary health care: Establishment of Hospital Development Committees

Improvement of infrastructure and facilities.• Establishing e-Health• Health financing:

Performance based incentives to providers: CBHI initiatives: Implementing the Food Safety and Standards Act, 2006.

• Essential medicine:

12th Five year Plan (2012 – 17):• Universal Health Coverage (UHC) • Substantial expansion and strengthening of the public

sector health care system

• Effective Public Health Administration:

– Public Health Act/Public Health cadre, – Health Management Cadre, – Mandatory practice of Clinical Treatment Guidelines and

prescription of generic medicines listed in the National List of Essential Medicines in all Government facilities

– Mandatory test audit of medical prescriptions by faculty of medical colleges

– Improve governance through citizen participation, social audit and greater transparency

– Grievance redress system• Health Financing: Increased expenditure on Health Sector • Health Regulation Extend and enforcement: Central

Clinical Establishment Act 2012• Development of Human Resource for Health

• Convergence and Stewardship

• Health Services Master plan:

Each district able to provide assured set of services to all its residents.

• Convergence across sectors for better outcomes.

Private health care system: Reforms

• Major player for health care delivery.

• Consume major share of health care spending.

• Unregulated, No standardization, No accreditation.

• Clinical Establishment (Regulation and Registration) Act 2010.

• Clinical Establishment (Regulation and Registration) Rule 2012.

• 12th Plan: Envisaging pvt. System to be alternative health care provider on public funding.

International Experience: HSR in USA:

• Health Care Reform 2010 (Obama Care):• Basically enactment of 2 laws:

• Patient protection and Affordable care bill (PPACA) 2010.• Health Care Education Reconciliation Act of 2010.

• Advantage of Obama Care– SBC: Summary of benefit and coverage :– Consumer Assistance Programme:– Appealing Health Plan Decisions– Preventive Care– Patient's Bill of Rights– Doctor Choice & ER Access– Grand fathered Health Plans

Health Sector Reform in Chile:

• A dual health care delivery system till year 2000.• Series of reforms after year 2000. • Citizen has choice: govt. National health insurance plan (68%) or one

of the private health insurance (18%).• Other 14% by other non- Profit insurance.• Duality in system, reduce equity.• Health Sector Reform (2000):

Universal Health Care plan: Medical Benefit Package: prioritized list of 56 diagnoses and treatment. Pre- Arranged provider network

Table 1: Variables used in an algorithm to establish a prioritized list of diagnoses and treatments for 56 health conditions covered under Chile’s universal health care plan:

Variable FeasibilityMagnitude Epidemiologic indicators, disability adjusted life years

and gaps in Mortality across socio-economic groups and user preferences.

Effectiveness Treatments of each health condition were stratified into high, medium and low levels of effectiveness. Conditions whose treatments had a medium to high level of treatment effectiveness were prioritized.

Capacity of the healthcare system

A particular health condition was prioritized when the capacity to deliver services was considered adequate.

Costs High-cost conditions (US$2 697 or more per annum) were prioritized.

Social consensus Debate and social consensus were elicited by forums and “deliberative dialogues” with scientific societies, medical associations, universities and policy-makers.

Measuring effect of Health Sector Reform

Effect Measure on following objectives:•Allocative Efficiency

•Technical Efficiency

•Equity in Access and Care

•Equity in Finance and

•Financial sustainability

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Countries: What Have We Learned? “Appraising a Decade of Health Sector Reform in Developing Countries”; March 15,2000; Washington, D.C.2000.

4. MOHFW, GOI. Health Sector Reform in India: Initiatives from States. New Delhi: 2007.

5. MOHFW, GOI. Health Sector Reform in India: Initiatives from Nine States. . New Delhi: 2007.

6. Planning Commission, Govt. of India. The Eighth Five Year Plan: Vol. New Delhi1992; Available from: http://www.planningcommission.nic.in/plans/planrel/fiveyr/index9.html.

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8. WHO. Methods for Evaluating Effects of Health Reforms. Division of Analysis, Research and Assessment, WHO, Geneva. 1993.

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