devaki nambiar phd, kabir sheikh mbbs mph phd health governance hub public health foundation of...
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Devaki Nambiar PhD, Kabir Sheikh MBBS MPH PhD
Health Governance HubPublic Health Foundation of India
4th Technical Review Meeting for the HPHFKH10th 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 AREASRegulation and stewardshipCommunity action for healthHealth workforce governance
Pharmaceutical policyUrban health governancePublic health philanthropy
As India moves towards Universal Health Coverage…
Sheikh, Saligram, Prasad (2010-2011)
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 careQuality of care
Accessibility of care
Accessibility of care
Conduct of providers
Conduct of providers
Costs of care for users
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
Delhi Madhya Pradesh (MP)
Cost of Care RSBY and government subsidies to private hospitals both aimed at reducing costs of private care for EWSDo 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.
Absence of credible community-based forum for grievance redress.
Conduct of Providers
Accessibility of Care
Not addressed through act or policy Variable workforce distribution, only mandatory rural service, no incentive based policies
Delhi Madhya Pradesh (MP)
Cost of Care Information 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 efficiencyDecisions are concentrated, flow in one directionPolicy 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
ARENACOMPLEX AND SOCIALLY CONSTRUCTED
Decisions are diffused, relationships are non-linear‘Software’ critical to health systems performanceProblems (and solutions) are related to (understanding) complexityShaped 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)
