Health sector reforms
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Health sector reforms aim to improve the efficiency, equity and effectiveness of healthcare delivery. Key reforms implemented in India include decentralization through expansion of comprehensive primary healthcare centers, increasing healthcare financing and expenditures, expanding health insurance coverage, reorganizing the existing health system, improving health infrastructure and human resources, implementing digital health initiatives, and encouraging public-private partnerships. Challenges remain in strengthening implementation and ensuring equitable access across states, but ongoing reforms indicate progress toward more accessible and comprehensive healthcare nationwide.
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Health sector reforms
- 1. HEALTH SECTOR REFORM Moderator: Prof. Romola P Presenters: Dr. Sanasam Jupitar & Dr. Avantika Gupta
- 2. SEMINAR OUTLINE What is Health sector reform How it evolved/history Objectives of health sector reforms How is HSR implemented HSRs in India
- 3. Introduction • Reforms are inevitable part of a developing and progressive sector • The same applies to the health sector • The prevailing persistent economic downturn, emerging and re- emerging diseases, and violent conflicts is forcing the health sector to reform even more in order to deliver in an effective, efficient and equitable manner
- 4. Health system “Combination of resources, organization, financing, and management that culminates in the delivery of health services to the population” (Milton I. Roemer 1991)
- 5. Key components of health system • State or government institution • Health care providers • Resource institutions • Purchasers of health care such as insurance agencies • Other sectorial agencies eg. Education, water supply, sanitation • Consumers or population at large
- 6. Fig: The WHO Health Systems Framework
- 7. • 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” Reform
- 8. 8 • Sustained purposeful change to improve the efficiency, equity and effectiveness of the health sector – Peter A. Berman (1995) • Defining priorities, refining policies and reforming the institutions through which those policies are implemented – Cassels (1997) Definition of Health sector reform
- 9. WHO Definition of Health sector reform • Health sector reform is a sustained process of fundamental change in policies and institutional arrangements of the health sector, usually guided by the government • It is aimed at improving the functioning and performance of the health sector and, ultimately, the health status of the population
- 10. The Forces Driving Health Reform • Rising costs in health care • Rising expectations • Limits on the capacity to pay • Scepticism about conventional approaches
- 11. Health sector reform deals with: • Equity • Efficiency • Quality • Financing • Sustainability
- 12. Health equity is defined as absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, geographically or by other means of stratification Equity vs Equality
- 14. Health sector reform deals with: • Equity • Efficiency • Quality • Financing • Sustainability
- 15. Major landmarks in health sector reforms • 1946-Bhore Committee put forward the concept of primary health care • 1974- Kartar singh Committee integrated cadre of MPWs • 1977- Gov of India launched a Rural health scheme based on the principles of placing peoples health in peoples hand recommended by Srivastav committee in 1975
- 16. Major landmarks in health sector reforms contd. • 1978- Alma-ata Declaration- Health for all through comprehensive PHCs • 1983- National Health Policy framed health for all by 2000 stress on preventive, promotive, public health and rehabilitation aspects of health care
- 17. Eight five year plan (1992-97) • Concept of free medical care revoked, • Free/highly subsidized care for the needy/bpl population • Private sector reforms Major landmarks in health sector reforms contd.
- 18. Ninth five year plan 1997-2002) • Convergence and increased involvement of public and voluntary health care providers • Enable PRIs in planning and monitoring of health programs • Inter sectorial coordination and utilization of local and community resources Major landmarks in health sector reforms contd.
- 19. Tenth five year plan (2002-2007) • Emphasis was on equity and financing health care • Social health insurances for BPL population- universal health insurance scheme • Focus on public private partnership Major landmarks in health sector reforms Contd.
- 20. National Rural Health Mission • Overarching Umbrella initiative which subsumes the existing programs of health and family welfare and seeks to be omnibus vehicle for sector wide reforms • Launched on 12 April 2005 • Now subsumed in National Health mission from 2013 onwards
- 21. Sustainable Development Goal 3 • It is one of the 17 Sustainable Development Goals established by the United Nations in 2015 • Mission statement "To ensure healthy lives and promote well-being for all at all ages."
- 22. Objectives of health sector reforms Goal: Health improvement or health gain Objectives : 1. Improved equity in health and health care services 2. Increased and better management of health resources 3. Improved performance of health systems and quality of care 4. Greater satisfaction of consumers and providers of health care
- 23. Financing Payment Organization Regulation Behaviour The Control Knobs in Health Reforms R reforms: ≥ 2 control knobs r reforms: 1 control knob
- 24. 1. Organization and management 2. Financing of health services 3. Public sector reforms Types of Health Sector Reforms
- 25. • Decentralization • Contracting out of services • Public-private mix Organization and management
- 26. • User charges • Community financing schemes • Insurance • Stimulating private sector growth • Increased resources to health sector Financing of health services
- 27. • Downsizing the public sector • Productivity improvement • Introduction of competition • Improving geographic coverage • Increasing role of local government • Targeting role of public sector through packages of essential services Public sector reforms
- 28. How to implement health sector reforms?
- 29. Define problem Policy Development Diagnosis Political decision Implemen- tation Evaluation Technical analysis • Social value judgement (explicit or implicit) • Feasibility & implementation analysis: a. Implmentability b. Political feasibility c. Political controllability • Identification of impacts of different policy options • Assess health system’s current performance: Health status ? Customer satisfaction ? Risk protection ? • Start with performance problems- undesirable outcomes • Ask ‘WHY’ five times • Work backwards • Interventions in 5 control knobs • Based on explicit analysis • Imitate but adapt : advices should be ‘conditional’ on local circumstances • Stakeholder analysis • Evidence based • Details matter in policy design • HSR is political throughout reform cycle • Requirement of political skill, not just political will • Political landscape analysis • National implementation capacity needs careful consideration • Administrative experience & managerial sophistication required • Ongoing attention with support from highest levels of Gvt. • Issues of data cost, quality & reliability need to be considered • Reforms require continuous process of learning & adaptation as conditions change • Before-after comparison • ‘Difference in differences’ approach
- 30. Health sector reforms in India
- 31. Decentralization Human resources Financial reforms Reorganization & restructuring of existing health system HMIS Communitization Quality assurance Digitalization PPP
- 32. Decentralization
- 33. • India has at least 31 lakh operational NGOs (CBI, 2015) • One NGO per 400 population NGO involvement Decentralization Distribution of NGOs by activities across major states Pattern of activities under health across states for different NGOs:
- 34. ↑ HRH density to achieve WHO norms of ≥ 23 HCW/10,000 pop & 3 nurses/ANMs per doctor New medical college by upgrading district hospital in under served districts ↑ No. of seats ↑ PG institutes & adm. Under AYUSH • 179 new medical colleges ~ 558 medical colleges total 289 Gvt run 269 Pvt. sector Human resources No. of seats 2014 2020 Inc (%) MBBS 54,348 83,275 53.22 PG 30,191 54,275 80.00 MSC (N) 10,784 13,322 23.53 BSC (N) 83,192 1,00,865 21.24 GNM 1,15,844 1,30,182 12.38 ANM 52,479 55,490 5.73 India: MoHFW, Dept. of AYUSH 2014 2016 No. of PG inst. 145 164 Capacity 3388 4114
- 35. Financial reforms • Between FY15-FY21 BE, India’s PHE: 1.2% to 1.8% GDP ↑ Gvt. Spending on health to 2.5% of GDP by 2025 (NHP 2017) Budget allocation 2019-20 Actuals 2020-21 Revised estimates 2021-22 Budget estimates Annualised change (Actuals 2019- 20 to BE 2021- 22) Health & Family Welfare 62,397 78,866 71,269 7% Health Research 1,861 4,062 2,663 20% Total 64,258 82,928 73,932 7% -Expenditure Budget 2020-21, PRS
- 37. • Contributed 20% to non-life insurance business Health insurance Could increase the penetration of health insurance in India from 34% to 50% 23rd September, 2018 - 10TH OCTOBER, 2021 Financial reforms MANIPU R
- 38. Reorganization & restructuring of existing health system It aims to provide Comprehensive Health Care Services (CPHC) closer to the community and reduce financial hardship
- 39. Key Milestones of AB-HWCs
- 42. Bi-directional Referral & Return Linkages for Continuum of Care with PMJAY
- 44. District Name Total Functional Total Footfalls No of Wellness sessions including Yoga conducted Total Screenings For HTN Total Screenings For Diabetes Total Screenings For Oral Cancer Total Screenings For Breast Cancer Total Screenings For Cervical Cancer Male Female Others Total Thoubal 30 24582 40409 2603 67594 8399 15162 11655 10801 6710 2304 Chandel 19 11055 15756 232 27043 1406 13761 11446 6570 3323 677 Ukhrul 13 33 31 0 64 1 248 43 2 6 0 Imphal East 47 33929 56246 259 90434 6950 31484 25322 26074 15997 1864 Imphal West 35 41797 67670 289 109756 7097 28905 24910 24896 13847 3342 Senapati 21 12363 17371 61 29795 2164 11803 5818 3512 2017 91 Bishnupur 22 15626 28394 667 44687 4015 15607 10745 9168 6002 228 CCpur 17 5274 7784 216 13274 1128 6850 6518 5739 3152 1250 Tameng- long 7 2153 3493 90 5736 222 2001 1334 317 264 0 TOTAL 211 146812 237154 4417 388383 31382 125821 97791 87079 51318 9756 Cumulative report of performance of AB-HWC in Manipur: 10.10.2021 In FY 2020-21: Manipur ranked 25
- 45. Some activities by HWCs of Manipur:
- 46. Awareness on Breast CA month World hospice day by CHO HWC Heikhrumakhong, Imphal East Fit Health Worker Campaign launched in Manipur: 2nd Oct, 2020 to 23rd Oct, 2020 World Mental Health Day observation
- 47. Manipur gets its first Transgender Health and Wellness Centre at JNIMS March 25, 2021 • PPP between India and the US • 1st of its kind in the NE India • Consists of two units Help desk inside JNIMS Wellness centre located across the JNIMS building
- 48. ACTIVITIES
- 49. Before After AB-HWC Selective primary health care Comprehensive primary health care Focus on reproductive age group Life cycle approach Limited availability of medicines, OOPE, ↓ treatment adherence Medicines & diagnostics at nearest HWC, follow up at community level Low utilization of vast network of SHCs & PHCs SHC/PHC transformed to AB-HWC ensures CPHC Limited HR at SC level 1 CHO at SCH-AB-HWC to lead No gate keeping function at 1◦ level More cases resolved at 1◦ level →↓ overcrowding at 2◦ & 3◦ level No access to tele-health Referral linkages via teleconsultation Manual reporting & monitoring Standardised digital health records Limited focus on wellness component Wellness activities: Yoga
- 51. Communitization State Health Society District Health Society Facility level: CHC/ DH: Rogi Kalyan Samiti AB-HWCs-PHC/ SHC: Jan Arogya Samiti (JAS) Village level (rural): VHSNC Slum (urban): MAS Jan Arogya Samiti (JAS) Quality service delivery (IPHS, NQAS, KAYAKALP) Health promotion: multi- sectoral action Grievance redressal: patient satisfaction survey Social accountability exercise
- 52. Quality assurance Quality healthcare’ is one of the motto of the scheme National Heath Authority (NHA) has collaborated with Quality Council of India (QCI) to use their well established systems, skill set and credibility to start a quality certification process
- 53. PPP Jan 2020, NITI Aayog: PPP model to link pvt. medical colleges with district hospital ‘User fee’ charges •Management contract •Purchasing of services •Build, operate & transfer model •Co-location model 4 PPP models
- 54. Digitalization of health care Launched on 27th September 2021 Ayushman Bharat Digital Mission (ABDM) AIM: To develop the backbone necessary to support the integrated digital health infrastructure of the country. It will bridge the existing gap amongst different stakeholders of Healthcare ecosystem through digital highways.
- 55. ABDM Ecosystem
- 56. Buildin g Blocks “Think Big, Start small, Scale fast’ Health ID Healthcare Professionals Registry (HPR) Health Facility Registry (HFR) Health Records(PHR) Standardize the process of identification of individual across health care providers Comprehensive repository of all Healthcare professionals involved in delivery of health care services across different systems of medicine Comprehensive repository of health facilities of nation across different systems of medicine E-record of health information on an individual conforming to nationally recognized interoperability std. & can be drawn from multiple sources
- 58. November 2019, eSanjeevani AB-HWC implementation was initiated under Ayushman Bharat Scheme of Government of India
- 59. Manipur CM launched ‘Covid-19 Vaccination Express’ on 11th Oct, 2021 • State Gvt. initiative in partnership with CARE India, an international non-profit organisation working on Public Health • To provide vaccination delivery at doorstep • Fifteen vans, equipped with all required facilities and 20 trained staff were dispatched to the Imphal West district
- 60. Project Swaraksha: 22nd May, 2021 Large countrywide campaign aimed to solve 'Vaccine Hesitancy' in Rural India
- 61. Project Swaraksha: 11th Oct, 2021 launched in Manipur In partnership with USAID-NISHTHA 20 villagers counselled in Manipur
- 62. Conclusion Reform is a cyclical process Success of health sector reforms lies with how the process is to be applied and by whom, rather than on how the contents are formulated
- 63. Way forward for effective HSR Incentive system to states Taxation Regulation of pvt. Sector Risk pooling Strengthening HMIS, Social audits, community monitoring, capacity building, prioritization, cost- effective policy Effective decentra- lization Increased public spending on health
- 64. References 1. Wamai RG, Ph D. Reforming health systems: the role of NGOs in Decentralization – lessons from Kenya and Ethiopia.pdf (application/pdf-object). 2000;(1998):1–19. Available from: http://www.istr.org/conferences/barcelona/WPVolume/Wamai.pdf 2. NITI Aayog. Investment Opportunities in India ’ s Healthcare Sector. 2021. 1–44 p. Available from: https://www.niti.gov.in/sites/default/files/2021- 03/InvestmentOpportunities_HealthcareSector_0.pdf. 3. Ministry of Health and Family Welfare. Towards Universal Health Coverage: Ayushman Bharat Health and Wellness Centers. A compendium of Health and Wellness Centers Operationalization. 2020. Available from: https://ab- hwc.nhp.gov.in/download/document/Towards_Universal_Health_Coverage_HWCO_14_12_2 0_for_web.pdf 4. NITI AAYOG. Guidelines for Public-Private Partnership for Non-communicable Diseases [Internet]. 2019. Available from: https://www.niti.gov.in/writereaddata/files/document_publication/NCD-PPP-GUIDLINE- BOOKLET.pdf 5. Ministry of Health and Family Welfare. Guidelines for Jan Arogya Samiti. Ministry of Health & Family Welfare G of I. Ayushman Bharat- Health and Wellness Centres. Minist Heal Fam Welfare, Gov India [Internet]. 2019; Available from: https://ab-hwc.nhp.gov.in/home/aboutus 6. Ministry of Ayush | Home [Internet]. [cited 2021 Oct 13]. Available from: https://dashboard.ayush.gov.in/ 7. National Health Auhtority. Ayushman Bharat Digital Mission. Official website Ayushman Bharat Digital Mission [Internet]. [cited 2021 Oct 13]. Available from: https://abdm.gov.in/home/ndhm
- 65. THANK YOU