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Submitted by Shankar Prinja on
I would tend to agree with Dr Ahuja’s statement that the Governments should be responsible for provision of health care to its citizens. Not so long back ago, Kenneth Arrow proposed his classical theoretical justification for Government action in provision of health care citing reasons such as information asymmetry leading to failure of markets in health care provision. More recently in an analysis of OECD countries and US, Wagstaff et al (2009) has shown that countries which finance health through tax money perform best in terms of health of its people followed by social insurance, and privately funded health care systems. Even the proponents of egalitarian systems propose the same order of health care financing on grounds of social justice (Wagstaff et al, 2001). All extreme examples from African countries and elsewhere, where attempts have been made to completely sideline government from financing/ provision have led to disastrous results, not only for health care of people, but also on overall economy of countries (Creese et al, 1997). Success of public private partnerships have largely hinged around strong leadership within the bureaucracy and political front, besides support from the health-care providers. Limited examples of public-private partnership on a focal scale such as the Chiranjeevi scheme in Gujarat have documented success. Similar attempts at provision of MCH services in urban slums in Haryana through VIKALP scheme could not take off the ground. Even if we consider that such successful schemes can be up-scaled, it is difficult to model such service provision for a whole gamut of health care services. The need of the hour is to address the real determinants of poor access and utilization of services for health care services in public sector institutions in rural India. These determinants of utilization, which we have known since long include: 1. Infrastructure: Poor service availability, lack of supplies and consumables 2. Manpower: Lack of health care providers round the clock 3. Funds: Lack of funds availability at institution level for undertaking minor repairs, maintaining supplies etc. 4. Poor quality and non-responsive services at public health care facilities. 5. Cost of OOP expenditure: Mainly on part of purchase of drugs in OPD care. NRHM is trying to address the first four determinants of service utilization at the public sector institutions. There are provisions for flexi-funds to upgrade infrastructure, recruit additional contractual staff as per need, and improve quality of care which is responsive to needs of community. The initiatives under National Rural Health Mission for rural India are in the right direction. Speaking from my personal experience, there is visible improvement in the health infrastructure i.e. building, supplies, manpower and funds availability, at health centres in Haryana and Punjab. However, there is little done for the last determinant of poor utilization at public sector facilities. Most studies from India, which show regressive effects of OOP spending in public health care facilities, reveal that the major component of OOP expenditure is on drugs (Vaishnavi et al 2010, Prinja et al unpublished). Despite this the number of drugs on essential drug list has shrunk from 170 in 1970 to mere 10 in 2005. A major reason for inaction on this front appears to be the major stakeholder power of pharmaceutical firms which do not let the agenda of essential drugs to appear in the policy discussions. I am short of exact figures, but considering that Governments spend so much on infrastructure and staff salaries, a relatively much lesser investment on availability of drugs at the health centres is found wanting. There is a need for greater devolution of powers at health centre SKS level to purchase the required essential drugs. Currently, powers are limited to purchase of emergency drugs only. In this light, the RSBY scheme is a step in right direction. There are two mechanisms of building competition and accountability: voice and choice. By ‘Voice’ we mean the act of beneficiaries to register their satisfaction or dissatisfaction with services. By ‘Choice’ we mean the option to beneficiaries to choose from a range of health care providers, which include both public and private. Currently the public and private providers do not compete for services and hence there is no role of choice in building accountability/ competition; and mechanisms to build voice are beginning to evolve. Evolving systems of performance-based funding is certainly an earnest attempt at building accountability. NRHM has developed measures like Rogi Kalyan Samitis and Charter of Services. However, these will still take time to evolve by the time capacity of community and community representatives at large to raise voice is built. There is a need to build incentive structures at local public health care facility level for health care providers so that they compete with the private health care providers. It is only then that such measures of building accountability actually translate into provision of quality health care services at public facilities. There is one major danger in any such attempt; crowding-in of services which are included in performance measurement matrix and vice-versa crowding-out of services which are not monitored for performance. Hence it can adversely affect the overall system and thus requires extensive detail in determining performance. The latter however puts too much demand on the routine management information system which is not geared towards providing such measures. Hence as a first step towards meaningful performance-based funding, there is an imperative need to strengthen the MIS system towards such holistic performance measurement.