health sector reform in india
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A Policy Analysis of the Health
Sector Reform Process in India
Dr. Rama Baru
Associate Professor, JNUIndia Habitat Center, March 7th, 2003
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A policy analysis of the HSR
process in India
The overall objective of this study is to explore
the perceptions and experiences of health sector
reform at the national levelIt specifically explores the definition, content,
process, and sustainability of the health sector
reform process in India.
It seeks to understand both the internal andexternal forces that are shaping the health sector
reform process.
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Definition of Health Sector
Reform
The definition of health sector reform used in thisstudy is that it is a fundamental rather than anincremental change, which is sustained rather than
one-off, [and] purposive in nature(Cassels:1997).
According to Cassels (1997) health sector reformincludes:
Improving the performance of civil service
Decentralisation of power and resources
Improving function of national health ministries
Broadening health financing mechanisms
Introducing managed competition
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Data Source: Interviews
Actor Numbers
contacted
Numbers
interviewed
Bilaterals (EEC, DfID,
SIDA roundtable)
7 7
World Bank 2 2
Ministry of Health and
Family Welfare
6 3
Tamil Nadu state level
policy makers and
academics
3 2
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Motivation for the Analyses of
Health Sector Reforms
Health Sector reforms are bound to influence the
provisioning, financing, manpower, drugs and
technology in the health service systemReforms will have a bearing on the effectiveness
of National Health Programmes.
Reforms will also have an impact on the
availability, accessibility, quality and cost ofhealth services-both general and specifically for
reproductive and child health
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Questions Pursued in the
Analyses
Varying definitions of health sector reform -Indian
government and major donor agencies
Motivation for reforms of different donor agenciesand the government
Content of health sector reforms
Implications of HSR for health services delivery
Sustainability of the reform process
Implications for equity
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Methodology
All who were involved in the health sector
reform process were contacted and key
persons were interviewed from the majormultilateral and bilateral agencies and the
Ministry of health and family welfare. The
donor agencies included The World Bank,DFID, SIDA, and the European
Commission
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Methodology
Elements of HSR that got special emphasis during
the nineties with loans/grants from multilateral
and bilateral agencies were reviewed; Loans to communicable disease control programmes
with focus on specific diseases viz. tuberculosis,
malaria and HIV/AIDs
Loans for the Reproductive and Child Healthprogramme
Loans to state governments for the state health systems
projects for primary, secondary and tertiary levels
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Plurality of definitions
Health sector reform is nothing more than projectsthat have been put together and it is tied to loans
from the World Bank. (Interview former Secretary
of MOHFW May 2002).During negotiating for the loans, the Bank told usthat unless we accepted conditionalities for powerreform they would not give us loans for health. We
told them that we did not want to be tied down bysuch conditionalities and would rather not get theloan. Then they came back to negotiate with us onthe terms set by us. (Interview with senior officialin the health ministry, Delhi, March 2002)
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Plurality of definitions
A senior official of The World Bank views health
reforms as a group of projects that includes
communicable diseases, Reproductive and Child
Health programme and Health Systems The
motivation for health sector reform as seen by the
World Bank is to promote economic efficiency,
quality, reform of public sector (Interview withSenior Bank Official, The World Bank Delhi
Office, March, 2002). .
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Plurality of definitions
The European Commission on the other hand arguesthat health sector reform is nothing more than a mixedbag of donors, projects and the government of India.
Overall there is a singular lack of vision among allthese actors when it comes to health sector reform.(Interview with Senior Official, EuropeanCommisssion, Delhi office, March 2002). They
consider the World Bank to be setting the agendaguided by some North American consultants tointroduce privatisation and have designed thecomponents of the health sector reform agenda for the
country. (Interview with Sr. official, EC Delhi office,March 2002
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Plurality of definitions
Some academics and researchers (based on recentstudies) on health sector reforms regard them aslargely driven by the World Bank, though
accepted by the national government in order toget loans to overcome the fiscal crisis, without acorresponding vision of the national government.
Some academics have pointed that it is the lack of
a vision of health sector reform within the ministrythat results in the identification of HSR with donorled initiatives (Interview with a senior healthresearcher, Chennai, April,2002).
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Space for negotiation
According to the European Commission the governmentdoes have space for negotiations in terms of theprogramme content and the choice of technology. Space
defined by vision, technical intellectual capacity ofgovernment officials and political will of stategovernments For example, user fees in Kerala and AP.
The role of the bureaucrats has been a mixed picture withthose who have a vision, some who collude with
foreign agencies and others who want to pursue theirown pet ideas ( Interview with Senior Official of the
European Commission, Delhi, March 2002)
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Space for negotiation
The bureaucrats from the health ministry opined that eventhough the World Bank was the major actor it did notdetermine the priorities for the country since the quantum offunding is small and not an additionality to the existingbudget.
Although the outlay is insignificant, a senior bureaucrat inthe health ministry argued that, we negotiated with theWorld Bank based on our needs. There was no element in
the disease control programme that was seen as unnecessaryby the Indian government. (March, 2002) The onlyprogramme that was pushed by the World Bank was forHIV/AIDS but the other disease control programmes namelytuberculosis and malaria were seen as important internally
and were endorsed by the Indian technocrats themselves.ibid .
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Space for Negotiation
At the state and central levels the push factor for
taking loans is the fiscal crunch faced by the
states. Given the poor state of finances, the state
governments opt for loans and see it as a way of
tiding over a financial crisis.
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World Banks Review of the Health
System Reform Project
The Banks image of itself as a provider of hardware and
infrastructure rather than a developer of human resources.
Resistance from Indian counterparts to address systemic
issues.
Shortages of resources and effective managers.
Focus on the public sector and on expanding the public
health system
Application of a single model to areas with very different
characteristics.
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Ownership of Reforms
The process of reform has been a top down with very littleinvolvement from the community. The plans are made at thecentral and state levels with very little input from the communitys
needs.As a result the ownership of reforms at the state and lower levelshas been weak.
Capacity weak at the state, districts levels
Resistance of public sector doctors to give administrative powersto Panchayats
Governance of public institutions unaddressed
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Implications for equity in access
and utilization
Privatization
Corruption
Rising cost of care, increasing cost of drugs,
user fees
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Sustainability of Reforms
Most state governments are not in a position toincrease allocations
In addition to sustaining these programmes, the stateswill have to also pay back the loans, which will onlyincrease their financial burden.
Frequent transfers of bureaucrats and technocrats asnegatively affect the implementation of the reforms.
Lack of civil service reforms
Corruption within the health services as an additionalimpediment to sustainability of reforms
Need for more effective donor coordination
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Major Issues
Definitionincremental not fundamental
The project approach to health sector reform
spaces are available for negotiations at both the centraland state levels with multilateral agencies.
Since nearly all state governments are facing a fiscalcrisis and health is not a high priority area of
investment, most of them have been applying for loansto the Bank.
The interviews suggest that the entire reform process isa top-down approach. There is little consultation
with the personnel at different levels of the health
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Major Issues
There is very little co-ordination among donors onhealth sector reform. There are situations where twoor three donors are operating in the same state with
their own priorities and agendas. This has raised theproblems of duplication and adhocism when it comesto programme implementation.
In the RCH programme the government has adopted
the Rights Based Approach after ICPD but this hasnot been effectively transferred to the different levelsof providers.
New budget?
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