Health Sector Reform: the Kerala experience V RAMAN KUTTY

Transcription

1 Health Sector Reform: the Kerala experience V RAMAN KUTTY 1

2 Theme of the discussion The context of reform initiatives The initiatives in detail The debate on the initiatives The context of the debate What was achieved- or not achieved- and why 2

3 The context of reform initiatives Mounting fiscal crisis affecting all government functions Perceived fall in quality of public services in health Erosion of public health functions 3

4 Reform initiatives-the beginning Limits to Kerala model : whether social sector spending is sustainable Increasing fiscal crunch in the eighties culminating in a crisis by the ninetiesoverdrafts, treasury shut downs etc. Increasing share of salaries and decreasing share of drugs and maintenance in public sector spending on health 4

5 The major initiatives The Expenditure Commission report and recommendations ( UDF) Decentralized planning ( LDF) Administrative Reforms Commission ( LDF) Fiscal Reforms Initiative- ADB TA ( UDF) Modernising Government Programme ( UDF) 5

6 Products of the initiatives Report of the Expenditure Commission Report of the ARC Committee on standardization of institutions Initiative on development of common protocols Manuals for PHC and other institutions- DSP Service Delivery Project 6

7 Major thrust areas of reform initiatives Improvement in finances of the public sector in health Increasing efficiency Increasing equity in access Improving quality of care Providing accountability in service and finances 7

8 Improving finances User fees (Expenditure Commission) Health Cess/ Health Fund (ADB TA) Health Insurance 8

9 Improving efficiency Greater control by local governments (decentralisation) Service Delivery Project (MGP) 9

10 Increasing equitable access Decentralization of control More money to lower level institutions (SDP) 10

11 Accountability Decentralisation Citizen s charter Standaridisation of services 11

12 Public health functions Administrative cadre 12

13 The debate on some of the recommendations: user fees Pro- can improve the finances of institutions, which are strapped for cash Con- will prevent access by the poor Con- health is a right In practice- did not improve finances as fees collected could not be used by institutions 13

14 Insurance Pro- poor pay anyway, so why not insure them, for ensuring minimum services Con- access is their right, insurance is not a remedy for malfunctioning systems Insurance in the long run will take money from people and deny them services In practice- never took off 14

15 Decentralization Pro- Effective control by LSG will improve access, as well as finances Con- Politicians will control functioning of health services Con- will promote corruption at the lower level In practice- works fine in some LSGs, where LSG and doctor are good terms; has not resulted in the kind of benefits expected 15

16 Decentralization- criticism Handing over health to non-technical people (professionals) Part of the World Bank Agenda: state withdrawing from health and other service sectors (left within the left) Reality- doctors still dominate health institutions; public institutions in health are collapsing and decentralization is one way of shoring them up 16

17 Service Delivery Project Pro- set out parameters of improved service delivery, gave an opportunity for institutions to think boldly of improving services Con- will not be sustainable In practice- some institutions made use of opportunity, mostly frustrated by structural problems in the system 17

18 Service Delivery Project- criticisms Part of the World Bank Agenda- withdrawal of services Reality- SDP envisaged no withdrawal of services, but more money to lower level institutions and better finances 18

19 What happened to specific initiatives? Administrative cadre- still exists on paper after a decade Standardization of services- report gathering dust, not implemented SDP- abandoned after change of government, about 40% of initial allocation spent Citizen s charter- put up by some institutionsno body pays any attention 19

20 Major issues which were never addressed Regulation of private institutions Re-orientation of manpower training at various levels to suit contemporary needs Changing the mode of functioning of government departments, which currently give incentives to promoting status-quo 20

21 The context of the debates Leftist political culture of the state- where external advice is resented Sharply divided polity- thin voter majorities decide policy matters Political hypocrisy- neither group has any qualms about criticizing what they know they will have to do once in power Strong unions of government workers resent any implication of greater accountability- exploitation Strong coalitions of groups with vested interest in the status quo- such as doctors, health workers, politicians Awareness of political class that deterioration of quality in health institutions unlikely to affect them- both personally and in terms of votes 21

22 What ails reform in health sector? Policy makers shared interests! Bureaucrats Professionals Public 22

23 What is the solution? Strengthening decentralization- more participatory decision making in health institutions Building accountability- holding professionals to accountable to minimum levels of service Strengthening finances- more equitable, prepayment modes of finance to be thought of Accountability in the private sector 23

24 How do we achieve this? Building coalitions of interested groupsactivists, public health advocacy groups, women s groups- to demand rights Keeping the debate alive- not letting it die out in a public institutions in health are beyond repair mindset Promoting flexibility- where any improvement should be welcomed, and not insisting on only one path to salvation 24