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Decentralization of Health Care Delivery – Search for and Ideal Indian Model: Summary & Way Forward

Decentralization of Health Care Delivery – Search for and Ideal Indian ModelSummary & Way Forward Search for an Ideal Model Common threads Health System Problems Health System Problems Health System Problems Health System Problems Health System Problems Health System Problems Ingredients of Successful Models Ingredients of Successful Models Ingredients of Successful Models Ingredients of Successful Models Ingredients of Successful Models Participatory organizational structure Ingredients of Successful Models Principle of Autonomy Ingredients of Successful Models Ingredients of Successful Models Ingredients of Successful Models Ingredients of Successful Models Issues Challenges Case of Gujarat Case of Gujarat Decentralization of Health Care Delivery –Search for and Ideal Indian ModelSummary & Way ForwardIndiraHirwayDarshini MahadeviaA Forum of Federations conference onDecentralization of Health Care Delivery in India –New DelhiFeb. 8 to 10, 2004Search for an Ideal Model•No one ideal model•Principles underlying successful models need to be understood•From international and Indian experience, some of the ingredients of the successful models could be identified from this workshop•A set of models could be developed for different situationsCommon threadsInternational & Indian experience•Uneven health status•Poor and informal sector left out•Lack of finances –within federal structures•Shortage of technical staff•Quality of services•Impact of globalization•Gender issuesHealth System ProblemsPolicy Level•No comprehensive health policy•Government Expenditure in health is still low –1.7% of GDP•Declining Public Investments and Expenditures in Health and Healthcarei)growth of private capital and stagnation of public investmentii)Abdication of responsibility by government, central and state•Many schemes floated but no money to them•Devolution of responsibilities but not financial powers•There has been decline in health care facilities in the period of reforms & breakdown of the Public Health System and declining accessHealth System Problems•Health policy primarily remains family welfare policy•Resurgence of Communicable Diseases•Absence of Regulation and Control, and Quality Standards in Private Healthcare•Corporatizationand rising costs of healthcare•There are high inequalities and continued discrimination•Increased demand on health system because of increasing conflicts and violence, environmental degradation•Health status improvement has deceleratedHealth System ProblemsData Level•No appropriate and adequate data of the health status, health costs, health facilities•Recent RCH data could be used for developing some decentralized data at the district level•Decentralized planning requires decentralized & quality dataHealth System ProblemsAt management level•Frequent transfers in bureaucracy and health staff that does notpermit continuity•Low variable expenditure allocations, that is for maintenance and operations. Not congenial to attracting doctors and nurses•High expenditure on capital. There is no money for buying medicines but there is money for making a building.•Just Rs. 1.5 per capita per year on medicine in Gujarat•Lack of commitment of health care staff, especially para-medical staff. E.g. ANM.•Accountability of medical staff of public health facilities not built in•High expenditure on salariesHealth System Problems•No money, less spent, and even then there is misuse of money. Even external funds are misused or wasted.•Gujarat, Maharashtra and Karnataka are states where PHCshave been made a responsibility of PRIs, from 1964 onwards. There is no experience of Gujarat that suggests that the PHCsor public health facilities have improved after being made responsibility of the Panchayats.•Panchayatsdo not have a good system of auditing of accounts •Whether Panchayat Rajhas improved the situation? It might have helped in decentralizing corruptionHealth System Problems•Lack of utilization of local knowledge on health•There is lack of referral care at the local level. Where one would go for specialized facilities.•Malpractices exist on a large scale in urban Gujarat. Nexus of pharmaceuticals and doctors.•For a poor household, health expenditure leads to increased debt and hence high vulnerability to poverty.Ingredients of Successful ModelsAt the national level•Strong national commitment to comprehensive health care for all•Health care as a right•Commitment of finances for health care•Commitment to decentralization backed by devolution of financial and administrative powers•Health care at affordable rateIngredients of Successful ModelsAt the state level (mid-level)•Financial and administrative autonomy•State-level commitment to resources•Devolution of resources and power to lower level•State level health policy –macro policies and sectoralpolicies•Facilitating decentralization through legal, financial, administrative and organizational measures•Equal emphasis on rural and urban areasIngredients of Successful ModelsAt Micro level•Universal health care for all irrespective of gender, caste, class, religion, etc.•Comprehensive health care –at individual level, community level•To include primary, secondary and tertiary care•Preventive health issues to be addressedIngredients of Successful ModelsFinances -Sources•Adequate and automatic devolution of central and state finances to the local level on per capita basis•Local level taxation•Beneficiary contribution at affordable rates –through fees, labour, etc.•Donations and other contributions1.This requires new legislation for devolution of functional & financial powers and autonomy2.Requires affordable insurance coverage (Columbia)Ingredients of Successful ModelsOrganizational•Evolving of an appropriate system of health care (today there is a total anarchy) for rural and urban sectors specially•Appropriate hierarchy of services•Participatory•Local responsiveness & responsibilities•Setting up of referral linkages•Flexible and facilitative government structure•Autonomy of decentralized structuresParticipatory organizational structureParticipation -with appropriate role for each participantCommunity participation and partnershipsPublic –community (RKS)Public –NGOPublic –privatePublic –private –NGO (SEWA)Ingredients of Successful ModelsProper organizational structure will lead to•Staff & their motivation•Identification of needs•List of services to be provided•Quality•Planning, Monitoring & evaluation•Local record keeping•Proper roles of every one involvedPrinciple of AutonomyFinancial autonomy•Raising resources•Utilization of resourcesAdministrative autonomy•All decision-making•Human resource managementIngredients of Successful ModelsMonitoring•Developing indicators for monitoring of outcomes, processes.•Setting up institutions for monitoring (e.g. councils in Brazil or RKS in MP, Chhatisgarhetc.)•Monitoring with participation of local peopleAccountability & Transparency•Regular publishing of annual reports, including financial functional report at all levels•Social auditingIngredients of Successful ModelsInnovative and culture specific models•Scope for innovations to be identified•Experiments to be recorded an evaluatedAssist communities to demand health care right•Unless people demand quality, system may not improveIngredients of Successful ModelsCapacity Building at the local level•Of local health care givers•Empowerment of women•Training for various tasks and use of technology, record keeping, need assessment, planning, etc.Ingredients of Successful ModelsTechnical support•Building of capacities of medical and para-medical staffSetting up of State level cell to support•Staff•Rules for autonomyIssues•Ensuring of Access to All in a highly fragmented society•Proper representation of people at the micro level –gender, class, caste social group•Health care services to the door stepChallenges•Decentralization has improved access. But, there has to be proper representation of the marginal groups and women•Raising finances•Maintaining equity and efficiency•To make health a political agenda•Committed and competent technical staffCase of Gujarat•Gujarat HDR –2003-In health sector, state at 9thposition among 15 large states-Deceleration in improvement in most indicators in 1990s-Problems at macro, regional and micro level•There are micro level success models as well•There is a need to compile experiences of the success stories, learn from them and attempt scaling-up•In this context, ORF’sinternational seminar and lessons from other countries very useful.•CM of Gujarat has shown interest in thisCase of Gujarat•Interventions are needed in:-State-level health policy for integrated and comprehensive health care system-State-level facilitative sectoralpolicies-Decentralization facilitated through legal, organizational, administrative & financial & mechanisms-Organizing decentralized health services•Need to prepare a concept paper –may be through a small committee•Developing micro models where the basic principles discussed above are put in place•Pilot project –under a state level committee