Posts Tagged ‘Sector’

Health Sector Reforms In Andhra Pradesh

Thursday, November 12th, 2009

Reforms in

    A review on reforms in India   The reforms in India were started way back in 1970s .The Govt. of India identifies the need and stated in the eighth five year plan. The Eighth Five Year Plan (1992-1997) was the first to state the need for re-structuring of systems, following the macro developments of the 1990s. During this period in the , the concept of was revoked and people were required to pay, even if partially, for the services (1). The Ninth Five Year Plan (1997-2002) emphasized the need to review the response of the public, voluntary and private care providers as well as the population themselves to the changing scenario, to reorganize services to bring about greater efficiency and effectiveness and to introduce system reforms to enable the population to obtain at affordable cost The Ninth Plan sought to increase the involvement of voluntary, and self-help groups in the provision of care and ensure inter-sectoral coordination in implementation of programmes and -related activities as well as enable the (PRI) in planning and monitoring of programmes at the local level so as to bring about greater responsiveness to needs of the people and greater accountability; to promote inter-sectoral coordination and utilise local and for care(2) .The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary and tertiary level(3).                         Politics influence systems in significant manner. The goals, priorities, and the strategies, variations in the commitment are largely decided through the political . There are competing demands on the systems. The evolution of the systems is largely shaped by the culture, history, and norms. Client satisfaction is very high. As per NFHS-2 data, an overwhelming majority of clients are satisfied by the services delivered by the public systems. May be the expectations are low or may be our people are so courteous. But on the hand, we have the report from Transparent International, ranked the system in India is the most corrupt system (4)   The Government has taken several steps for improving the public care institutions and Strengthening the primary care infrastructure. However, the situation is compounded by severe resource constraints – financial, technical and human power related, which has resulted in policy makers as well as programme managers at differing levels being faced with difficult choices. In such a situation, attempts are being made through various reform initiatives to ensure that the needs of the people are met One of the major reform initiatives underway is the Secondary System Strengthening Project funded by the World Bank in seven states ( , Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar ). The projects include strengthening FRUs/CHCs and district hospitals so as to improve the availability of emergency care services to patients, to reduce overcrowding at district and tertiary care hospitals, construction works, procurement of equipment, increased availability of ambulances, drugs; improvement in quality of services following skill up gradation training in clinical management, changes in attitudes and behavior of care providers; reduction in mismatches in personnel / infrastructure; improvement in hospital waste management, disease surveillance and response system. It is essential to assess both progress and problems in implementation of the reforms in each state and to appropriately modify the content and pace of implementation. Such an overview and analysis of all related issues is necessary to provide evidence to policy makers and other stakeholders in terms of the various dimensions and impact of reform.(5) In the Indian Constitution, is a state responsibility. During Adjustment, many state governments in India had recourse to Systems Development Project loans from the World Bank for carrying out reforms (), of which one of the key policies has been to raise public spending on care from the abysmally low levels seen up to then. The Systems Development Project seeks to develop strategic management capacity; strengthen performance, accountability, and efficiency; and build implementation capacity. Further, it seeks to improve clinical service quality by renovating and expanding district, sub district, and community hospitals and improving access to services. In all seven reforming states, around 15% of the total project cost is borne by the state governments. All the project documents note the low levels of funding for secondary hospitals in the reforming states. This is attributed to the small share of overall public spending allotted to , the limited portion of total spending going to hospitals, and, within this, a skewed distribution of funds in favour of the tertiary hospitals. After analysis of the problems of the , the governments of the reforming states have agreed-using terminology ranging from “assurances” to “commitments”-to several undertakings. These are: (i) to enhance the overall size of the budget; (ii) to redress imbalances in public expenditure between secondary and tertiary care levels; (iii) to safeguard the operations and maintenance components of current expenditure allocations for the secondary -care ; (iv) to charge user fees for selected services; and (v) to address workforce issues. The Systems Development Project initiated in the seven states recognizes the need for enhanced public spending on and identifies it as the foremost policy reform to be pursued. Nevertheless, such assurances and conditions have not succeeded in enhancing budgets in states implementing . Worse, has not been able to arrest the decline in the share of spending within total government spending. The Indian system is especially complicated, as the larger tax resources are controlled by the central government but the major responsibility for -care spending is bestowed on the states (6). is the first state to go with the .               reforms in   The state of was formed on 1st November, 1956 under the States’ reorganization scheme. It is the fifth largest State with an area of 2, 76, 754 sq. km, accounting for 8.4 % of India’s territory and also the fifth most populous state with a Population of 75 crores. The state has varied physiographic features ranging from high hills, undulating plains to a coastal deltaic environment. Administratively, is divided into 23 districts, 79 revenue divisions, 1123 mandals, about 27000 villages and 264 towns. AP’s economy grew at 7.2% during 2006-07 — the fourth consecutive year of 6% plus growth. The latest poverty headcount ratio stands at 16%, compared to 23% for India . the third-highest credit rating among the major Indian states; the third best investment climate in the country; and the fourth-lowest corruption level among Indian states was the first Indian state to receive a multi- Bank operation – the Economic Restructuring Program for US$ 550 million in 1997 – aimed at helping the state accelerate policy and institutional reforms across a wide range of sectors under a common fiscal framework. It is also the only Indian state where the Bank has disbursed three budget support operations – the First Economic Reform Loan (APERL-1) in March 2002, the Second APERL in February 2004, and the Third APERL in January 2007 – that sought to support the state’s development program.(12) Within AP there are regional, social and gender disparities. outcomes are worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% of population), especially those living in underserved areas in North tribal and South drought prone districts, and for women. Effective delivery of quality basic services is hampered by demand and supply side issues, including poor infrastructure and staffing.(15)     The reform history in in the State can be traced to First Referral System Project, one of the first World Bank aided system projects in the country. This project, launched in 1995 had been implemented by AP Vaidya Vidhana Parishad (APVVP). Agencies like World Bank and DFID are supporting the reform process in the State. The Bank supported the AP Economic Restructuring Project which included improvement of primary care as one of the component.(7) The priority reforms focus on improved access to quality and responsive services, strengthened governance and management in , improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems.(15)  The government of [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for reform: providing universal access to primary healthcare; encouraging private investment in tertiary healthcare; focusing on specific programmes to promote family planning; focusing on improving levels in disadvantaged groups and backward regions; ensuring a strong prevention focus; enhancing the performance of the public system; and formulating a state information education and communication (IEC) programme to broadcast information on preventive healthcare.(13) The Government of is embarking on a major reforms to improve care delivery in the State. D.F.I.D. has expressed its willingness to support these initiatives with a grant of 100 Million pounds over the next five years (2006-2011). The reform initiative will include measures to improve the effectiveness and accountability of public services, measures to focus on community centric preventive healthcare system and enhance access to quality healthcare for the poorer sections of the population(14) DFID will provide up to £40 million budget support to the DoHMFW, GoAP, over 3 years 2007 – 2010. The support will build synergy with National Rural Mission (NRHM) which is a reform program of the central government for decentralisation, pro-poor focus, strengthening service delivery(15)     The support will be provided over three years (2007-08 – 2009- 10). It aims at increased use of quality services, especially by the poorest people and in underserved areas.(16) The main outputs will be: a) Improved access to quality and responsive services, especially in remote and interior areas; b) Governance and management of strengthened; c) Institutional mechanisms for community participation and systems for accountability in functioning; and Financial management systems strengthened and improved public expenditure on .   The performance of services would be measured against(17)

* greater effectiveness and improved outcomes of existing programs;
* improved efficiency in the allocation of resources;
* greater access and equity; and
* consumer satisfacfion

Reforms underway in   The major reforms underway are classified under these categories and the activities are noted below and we will look each of them in detail    (I) Reorganization and restructuring of existing government care system

Establishment of Vaidya Vidhana Parishad Strengthening of referral institutions and fixing of service norms Improvement in drug supplies Formation of , Medical & Housing Infrastructure Development Corporation (APHM&HIDC) Strengthening of PHCs as 24-hour MCH centers Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres

(II) Changes in system organisation, delivery and Management

Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals Provision of free travel bus passes to pregnant women for antenatal check ups Public Private Partnership

(III) Changes in financing methods

Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme) User fees

(IV) Reforms related to human resources

Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department

(V) Involving community in service delivery and Provision

Women Volunteers Scheme

(VI) Reforms to quality of care

Performance indicators for grading the PHCs Performance rating of secondary hospitals

    1.Reorganization and restructuring of existing government care system   A) Vaidya Vidhana Parishad   AP, has created the Vaidya Vidhana Parishad (APVVP) by enacting an Act in the Legislative Assembly in 1986(8) This was done with the objective to lay greater emphasis on development of both preventive as well as curative care  and to strengthen necessary linkages at appropriate levels to ensure comprehensive medical and care services. APVVP has undertaken World Bank assisted First Referral Systems Project (APFRHSP) in 1994 for a period of seven years. This has been one of the major projects undertaken by APVVP. The objectives of the project included improvement of efficiency in the allocation and use of resources through policy and institutional developments and enhanced performance of system by improving the quality, effectiveness and coverage of services at the first referral level.   B)Strengthening of referral institutions and fixing of service norms   basic service norms for various categories of hospitals under the administrative control of APVVP have been fixed thereby creating a hierarchy of hospitals according to services and facilities. This system of service norms and referral linkages had been developed with a view to optimise utilisation of resources, avoid duplication and wastage of resources, regulate patient flow and reduce cost of treatment by reduction of patient burden at tertiary hospitals. the district hospital has been prescribed to provide services in eleven specialties for which 9 civil surgeon specialists, 18-20 civil assistant surgeons, 54-84 paramedical staff and other supporting staff have been Posted. C)Improvement in drug supplies To ensure regular supply of drugs at all times and in all situations, a system of three sources of drug supply has been put in place for the hospitals under APVVP: (a) centralised drug procurement system under which the institution has been allotted drugs worth a particular amount based on bed strength (Rs 2000 per bed per quarter); (b) an emergency provision for drugs (Rs 100 per bed per month) has been made to every institution from where emergency procurement of drugs is made; (c) drugs which are in short supply and for which regular rate contract suppliers are not available have been stocked at the office of District Coordinators of Service. Under the APFRHSP, const-ruction and repair of 160 hospitals including 81 CHCs, 58 area hospitals and 21 district hospitals had been undertaken.(10)         D)Formation of , Medical & Housing Infrastructure Development Corporation (APHM&HIDC)   a separate corporation has been set up in 1987 exclusively for developing housing and other infrastructure for medical and paramedical staff and constructing sub centers, PHCs, hospitals, dispensaries, clinics and other care centers One of the major projects undertaken by APHM&HIDC has been the World Bank assisted India Population Project-VIII launched for improving the medical care facilities in urban slums in 74 municipalities.   E)Strengthening of PHCs as 24-hour MCH centers   In a move to make available maternal and child care at all times, 470 PHCs in backward districts have been designated as round the clock Mother and Child Centre (earlier called women centres). One staff nurse, one ANM and three support staff have been appointed in each centre on contractual basis. Staff nurses have been trained to conduct normal deliveries and refer emergency cases. Additional facilities like telephone and vehicle have been provided to the PHCs in order to assist communication and transport for referral of emergency cases. Provision has been made to conduct fortnightly specialist clinics of gynaecology and paediatrics in these centres to detect high risk pregnancies and neonates for referral to FRUs.   F)Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres   The State Government has decided to establish 108, CEmONC centres spread across every district so that pregnant mothers requiring emergency care do not have to travel more than 40-50 kms to receive specialist care. Training of MBBS doctors in anaesthesia, neonatal care and blood transfusion is also planned to support this scheme.   2)Changes in system organisation, delivery and Management A)Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals   Hospital Development Societies have been constituted in all tertiary hospitals under the control of Directorate of Medical Education.(18) and after implementing NRHM rogi kalyam samithi at every PHC were formed to ensure the adequate participation of local institution,with an aim to improve effective and efficient services with allowed flexible financial powers. These societies are examples for decentralization . Activities of the society include maintenance of the hospital (including sanitation & water supply, electricity, building & civil works and equipment), purchase of drugs & medicine supplies and equipment. The government has set norms and limits for undertaking these works which are to be adhered to by the Society. The ‘system works’, observed an Unicef team which assessed the impact of RKS towards the end of 2000. The system, however, is not without any lacunae. For, it was pointed out that “overall control of the local RKS bodies remain in the hands of the collector and if he is not interested in care then the whole thing might just drift(13)   B)Provision of free travel bus passes to pregnant women for antenatal check ups(19)   The Government of has started an innovative scheme in order to enable pregnant women in rural areas to avail antenatal check ups at the nearest PHC/area hospital or FRU. It has tied up with the State Road and Transport Corporation to issue free transportation bus tickets pass to be utilised for three visits. The ANM issues the bus passes to the pregnant women on her house visits.       C)Public Private Partnership(20)   ·         Management of Urban Centers by NGOs   Under the World Bank assisted Urban Slum Care Project (APUSHCP), 192 urban centers (UHCs) have been established in 74 municipal towns in 21 districts covering 1848 slums. After withdrawal of support by the World Bank, the project has been funded by the state government since 2002. The outcomes of the project show marked improvement in ANC coverage, institutional deliveries, post natal care and immunisation in the slum population.   ·         108 emergency services                           Govt. has tied up with satyam computers to provide emergency transportation which proved to a most successful programme and many states are following the same like Gujarath. The objective of 108 Ambulances is to save people in life emergency . One ambulance is given for three mandals. Each ambulance fitted with equipment worth Rs.17 lakhs renders its services in life emergencies, road and fire accidents (22)   ·         Rajiv arogya sree    The innovative Govt. insurance scheme to serve people of  poor from the serious ailments now attracting the nation as this programme succeeded. this scheme provides financial support to families of BPL upto 2 lakhs per anum for treating serious ailments. it is proposed to cover the entire state by 2nd October 2008 with the govt. paying the insurance premium for all the beneficiaries .an amount of rs.450 crores are provided to implement the scheme during 2008-09. (21)       3)Changes in financing methods   A)Sukhibhava Scheme(23)   Under the Scheme, a cash assistance of Rs.300 (Rs 200 towards transportation charges and Rs 100 for food and incidental expenses) is paid to pregnant women belonging to below poverty line families who come to government hospitals/APVVP hospitals/ teaching hospitals/PHCs/CHCs for delivery serv-ices. This assistance is payable only to those women with no living children or with one living child.   B)User fees:-   If user fees are charged their main use may lie in optimization of expenditure patterns and better allocation between facilities and within facilities(24). Reddy and Vandemoortele (1996), based on a comprehensive review of user financing of basic social services carried out for UNICEF, point to three other discouraging features of user fees: (1) user financing can result in a sharp reduction in the utilization of services, particularly among the poor; (2) gender biases, seasonal variations and regional economic disparities can aggravate the effects of user financing on equity; (3) user financing  quires adequate capacities, effective decentralisation and continued government support; and (4) user financing can undermine political support for the goal of universal coverage of basic social services. In 2001, the Commission on Macroeconomics and (2001) also reached a similar conclusion that user fees end up excluding the poor from essential healthservices, in 2005, the Millennium Project’s recent Report to the UN Secretary General (2005) titled “Investing in Development – A Practical Plan to Achieve the Millennium Development Goals” also forcefully argues for abandoning user fees. The in India has acquired a notorious reputation for inefficiency and corruption at all levels. There is little accountability in both the public and private sectors. Quality standards are practically non-existent as are performance measures and honest reporting. A recent report on human resources for brought out by Harvard University’s Global Equity Initiative (2004) argues that it is people – workers alone – who can produce an effective system and deliver good ealth.(25) 4)Reforms related to human resources Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department At district level, District Coordination Committee (DHCC) has been constituted to ensure proper planning, implementation and monitoring of all programmes/activities of HM&FW Department in the district.  The Committee has been entrusted with the primary responsibility of planning, finalizing, implementing and monitoring the District Action Plans and institutionwise plans in a participatory manner including all concerned officials, other concerned departments and NGOs.   5)Involving community in service delivery and Provision  

Women Volunteers Scheme

  One of the key components of the National Rural Mission is to provide every village in the country with a trained female community activist – ‘ASHA’ or Accredited Social Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public system. Following are the key components of ASHA(26) A woman, usually a daughter-in-law of a house who has studied upto 7th class and preferably from SC/ST community has been selected as WHV by the Gram Panchayat Committee. The selected WHV has been given one month training in care aspects of pregnancy, antenatal, delivery, post natal and new born care, immunisation, diarrhoea, acute respiratory infections, first-aid and treatment of minor ailments. The training has been provided at Telugu Mahila Pranganams for three weeks and one week field level training at PHCs. Academy of Nursing Studies has been designated as the nodal agency for providing training to WHVs.   6)Reforms to quality of care   A)Performance indicators for grading the PHCs   One of the components of World Bank assisted AP Economic Restructuring Project is improvement of primary care. In order to improve the quality of primary care services, a system of performance rating has been developed to rate PHCs and CHCs. The grading has been accorded A to C in descending order   B)Performance rating of secondary hospitals   A performance rating system for secondary hospitals under APVVP has been  introduced. The indicators related to general services (outpatients, inpatients, bed occupancy), emergency services (emergency-OP, emergency-IP, emergency major operations, emergency minor operations), clinical services (major/minor operations, tubectomy, deliveries) and diagnostic services (X-ray, ECG, lab tests and USG) have been developed for the purpose. Normative targets for each type of hospital (district hospital, area hospital, community center) have been fixed against which the performance is measured and rating assigned. Highest grading is A while lowest grading is C.(27)   Conclusion:-   Introduction of user charges and subcontracting of services to the private are the main elements of reforms. The reforms are only a part of drastic reforms in other major sectors undertaken as a part of Economic Restructuring Project (APERP) and the overall impact on the conditions of people and their access to medical care depend more on the changes proposed outside the . For instance, while exempting the white ration card holders i.e. the poor from the user charges in the government hospitals, it proposes to drastically reduce the number of white card holders to half in the state. The net affect would be to reduce the percent of population eligible for free treatment.(29)   On the other hand the success of 108 EMRI services and overwhelming response from Rajiv Arogya sree scheme are the examples for success. Just like every thing has gots its own pros and cons should be done in such a way where the need exist and according to necessities .   Referances:-   (Note:-most part of the article was taken from ref.no 28 otherwise reference specified)

 

(Government of India, Eighth Five Year Plan, (1992-1997) Planning Commission, New Delhi.) (Government of India, Ninth Five Year Plan, (1997- 2002) Planning Commission, New Delhi ) ( Government of India, Tenth Five Year Plan (2002-2007) Planning Commission, New Delhi) ( D. Agarwal Reforms: Relevance in India, Indian Journal of Community Medicine Vol. 31, No. 4, October-December, 2006) Reforms in India, Initiatives from Nine States ( http://www.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html.The international development research centre) http://www.worldbank.org.in  (The Vaidya Vidhana Parishad Act 1986 (Act No. 29 of 1986 with Amendaments upto 31.03.1989  Dr. MCR Human Resource Development Institute of (Undated). “ Vaidya Vidhana Parishad Departmental Manual”  6http://www.aponline.gov.in/apportal/departments/ departments.asp?dep=16&org=98 GoAP (2006), Response to Questionnaire on Reforms from MOHFW, GoI. http://www.worldbank.org.in/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/INDIAEXTN/0,,contentMDK:20970681~pagePK:141137~piPK:141127~theSitePK:295584,00.html#Ongoing_projects Grish kumar,promoting PPP in services,EPW commentary,july19,2002  (G.O.Ms.No.130, MEDICAL AND FAMILY WELFARE (K2) DEPARTMENT. Dated the 24th April, 2006)   REFORM PROGRAMME (APHSRP) Terms of reference for Technical Cooperation (TC) to DoHMFW, GoAP  PRESS INFORMATION BUREAU GOVERNMENT OF INDIA, HEALTHCARE PROJECT IN AP FUNDED BY DFID, New Delhi, March 5, 2008) http://lnweb90.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/0CFD6217A8A5BDA2852567F5005D32BD  G.O.Ms.No.403, dated Sept 7th 1998  GoAP (2006), Response to Questionnaire on Reforms from MOHFW, GoI. Power Point Presentation of Govt of AP at the 2nd Regional Workshop on Reforms: Experiences of Select States at Hyderabad, 14-15th February 2005 and ECTA Working paper 2002/61 Public-Private Partnership: Operational Framework used in and Assam http://www.scribd.com/doc/2208678/AP-Budget-Speech  http://pibhyd.ap.nic.in/er27070702.pdf  Dept. of Medical Family Welfare, GoAP (undated), “Sukhibhava (Improvement of Institutional Delivery Services Scheme): Implementation Guidelines to PHC/Hospital  http://mohfw.nic.in/NRHM/Documents/CRM_report_full_report_version.pdf   (A.K.Shiv Kumar,,Budgeting for ,some considerations) Economic and Political Weekly April 2, 2005  http://mohfw.nic.in/NRHM/asha.htm#abt http://.ap.nic.in/apvvp/apvvp_stat.html  (http://www.whoindia.org/linkfiles/health_sector_reform_hsr_vol_ii_-_andhra_pradesh.pdf)  (Impact Of Reforms On Hospital Services In – A Study Of Trends In The Structures Of Provision And Utilisation Pattern)(centre for economic and social studies) (http://www.cess.ac.in/cesshome/research6b.html)

       

 

6 yrs experience in public working with Govt. of of INDIA

305 | posted at November 12th, 2009 in department health | Tags: , , , , , , , , , , , , , , , , , , , , , , , ,

Powered by Yahoo! Answers