HEALTH SECTOR REFORMS

1. HEALTH SECTOR
REFORM
Moderator: Prof. Romola P
Presenters: Dr. Sanasam Jupitar &
Dr. Avantika Gupta

2. SEMINAR
OUTLINE
What is Health sector reform
How it evolved/history
Objectives of health sector reforms
How is HSR implemented
HSRs in India

3. Introduction
• Reforms are inevitable part of a developing and progressive
sector
• The same applies to the health sector
• The prevailing persistent economic downturn, emerging and re-
emerging diseases, and violent conflicts is forcing the health
sector to reform even more in order to deliver in an effective,
efficient and equitable manner

4. Health system
“Combination of resources, organization, financing, and management
that culminates in the delivery of health services to the population”
(Milton I. Roemer 1991)

5. Key components of health system
• State or government institution
• Health care providers
• Resource institutions
• Purchasers of health care such as insurance agencies
• Other sectorial agencies eg. Education, water supply, sanitation
• Consumers or population at large

6. Fig: The WHO Health Systems Framework

7. • A change for the better or an improvement
• As verb “to improve by alteration, correction of error, or removal of
defects or to put into a better form or condition”
Reform

8. 8
• Sustained purposeful change to improve the efficiency, equity and
effectiveness of the health sector
– Peter A. Berman (1995)
• Defining priorities, refining policies and reforming the institutions
through which those policies are implemented
– Cassels (1997)
Definition of Health sector reform

9. WHO Definition of Health sector reform
• Health sector reform is a sustained process of fundamental change in
policies and institutional arrangements of the health sector, usually
guided by the government
• It is aimed at improving the functioning and performance of the
health sector and, ultimately, the health status of the population

10. The Forces Driving Health Reform
• Rising costs in health care
• Rising expectations
• Limits on the capacity to pay
• Scepticism about conventional approaches

11. Health sector reform deals with:
• Equity
• Efficiency
• Quality
• Financing
• Sustainability

12. Health equity is defined as absence of avoidable, unfair,
or remediable differences among groups of people,
whether those groups are defined socially,
economically, demographically, geographically or by
other means of stratification
Equity vs Equality

14. Health sector reform deals with:
• Equity
• Efficiency
• Quality
• Financing
• Sustainability

15. Major landmarks in health sector reforms
• 1946-Bhore Committee put forward the concept of primary health
care
• 1974- Kartar singh Committee integrated cadre of MPWs
• 1977- Gov of India launched a Rural health scheme based on the
principles of placing peoples health in peoples hand recommended by
Srivastav committee in 1975

16. Major landmarks in health sector reforms contd.
• 1978- Alma-ata Declaration- Health for all through comprehensive
PHCs
• 1983- National Health Policy framed health for all by 2000 stress on
preventive, promotive, public health and rehabilitation aspects of
health care

17. Eight five year plan (1992-97)
• Concept of free medical care revoked,
• Free/highly subsidized care for the needy/bpl population
• Private sector reforms
Major landmarks in health sector reforms contd.

18. Ninth five year plan 1997-2002)
• Convergence and increased involvement of public and voluntary
health care providers
• Enable PRIs in planning and monitoring of health programs
• Inter sectorial coordination and utilization of local and community
resources
Major landmarks in health sector reforms contd.

19. Tenth five year plan (2002-2007)
• Emphasis was on equity and financing health care
• Social health insurances for BPL population- universal health
insurance scheme
• Focus on public private partnership
Major landmarks in health sector reforms Contd.

20. National Rural Health Mission
• Overarching Umbrella initiative which subsumes the existing
programs of health and family welfare and seeks to be omnibus
vehicle for sector wide reforms
• Launched on 12 April 2005
• Now subsumed in National Health mission from 2013 onwards

21. Sustainable Development Goal 3
• It is one of the 17 Sustainable Development
Goals established by the United Nations in
2015
• Mission statement
"To ensure healthy lives and promote
well-being for all at all ages."

22. Objectives of health sector reforms
Goal: Health improvement or health gain
Objectives :
1. Improved equity in health and health care services
2. Increased and better management of health resources
3. Improved performance of health systems and quality of care
4. Greater satisfaction of consumers and providers of health care

23. Financing Payment Organization
Regulation Behaviour
The Control Knobs in Health Reforms
R reforms: ≥ 2 control knobs
r reforms: 1 control knob

24. 1. Organization and management
2. Financing of health services
3. Public sector reforms
Types of Health Sector Reforms

25. • Decentralization
• Contracting out of services
• Public-private mix
Organization and management

26. • User charges
• Community financing schemes
• Insurance
• Stimulating private sector growth
• Increased resources to health sector
Financing of health services

27. • Downsizing the public sector
• Productivity improvement
• Introduction of competition
• Improving geographic coverage
• Increasing role of local government
• Targeting role of public sector through packages of essential services
Public sector reforms

28. How to implement health
sector reforms?

29. Define
problem
Policy
Development
Diagnosis
Political
decision
Implemen-
tation
Evaluation
Technical
analysis
• Social value
judgement (explicit
or implicit)
• Feasibility &
implementation
analysis:
a. Implmentability
b. Political
feasibility
c. Political
controllability
• Identification of
impacts of different
policy options
• Assess health system’s
current performance:
 Health status ?
 Customer satisfaction ?
 Risk protection ?
• Start with performance
problems- undesirable outcomes
• Ask ‘WHY’ five times
• Work backwards
• Interventions in 5 control knobs
• Based on explicit analysis
• Imitate but adapt : advices should be
‘conditional’ on local circumstances
• Stakeholder analysis
• Evidence based
• Details matter in policy design
• HSR is political throughout reform
cycle
• Requirement of political skill, not just
political will
• Political landscape analysis
• National implementation capacity needs
careful consideration
• Administrative experience & managerial
sophistication required
• Ongoing attention with support from
highest levels of Gvt.
• Issues of data cost, quality & reliability
need to be considered
• Reforms require continuous process of
learning & adaptation as conditions
change
• Before-after comparison
• ‘Difference in differences’ approach

30. Health sector reforms in
India

31. Decentralization Human resources Financial reforms
Reorganization &
restructuring of
existing health
system
HMIS Communitization
Quality
assurance
Digitalization PPP

32. Decentralization

33. • India has at least 31
lakh operational
NGOs (CBI, 2015)
• One NGO per 400
population
NGO involvement
Decentralization Distribution of NGOs by activities across major states
Pattern of activities under health across states for
different NGOs:

34. ↑ HRH density to achieve WHO
norms of ≥ 23 HCW/10,000 pop
& 3 nurses/ANMs per doctor
New medical college by
upgrading district hospital in
under served districts
↑ No. of seats
↑ PG institutes & adm. Under
AYUSH
• 179 new medical colleges
~ 558 medical colleges
total
 289 Gvt run
 269 Pvt. sector
Human resources
No. of
seats
2014 2020 Inc (%)
MBBS 54,348 83,275 53.22
PG 30,191 54,275 80.00
MSC
(N)
10,784 13,322 23.53
BSC (N) 83,192 1,00,865 21.24
GNM 1,15,844 1,30,182 12.38
ANM 52,479 55,490 5.73
India:
MoHFW,
Dept. of
AYUSH
2014 2016
No. of PG
inst.
145 164
Capacity 3388 4114

35. Financial reforms
• Between FY15-FY21 BE, India’s PHE: 1.2% to 1.8% GDP
↑ Gvt. Spending on health to 2.5% of GDP by 2025 (NHP 2017)
Budget
allocation
2019-20
Actuals
2020-21
Revised
estimates
2021-22
Budget
estimates
Annualised
change
(Actuals 2019-
20 to BE 2021-
22)
Health &
Family Welfare
62,397 78,866 71,269 7%
Health
Research
1,861 4,062 2,663 20%
Total 64,258 82,928 73,932 7%
-Expenditure Budget 2020-21, PRS

37. • Contributed 20% to non-life insurance business
Health insurance
Could increase the penetration of health
insurance in India from 34% to 50%
23rd September, 2018
- 10TH OCTOBER, 2021
Financial reforms
MANIPU
R

38. Reorganization & restructuring of existing health system
It aims to provide Comprehensive Health Care
Services (CPHC) closer to the community and reduce
financial hardship

39. Key Milestones of AB-HWCs

40. Key
Components
of
AB-HWCs

41. CPHC 12
service
package
Expanded
services
being added
in
incremental
manner

42. Bi-directional
Referral &
Return Linkages
for Continuum
of Care with
PMJAY

43. Glimpse of
operational
AB-HWCs

44. District
Name
Total
Functional
Total Footfalls
No of
Wellness
sessions
including
Yoga
conducted
Total
Screenings
For HTN
Total
Screenings
For
Diabetes
Total
Screenings
For Oral
Cancer
Total
Screenings
For Breast
Cancer
Total
Screenings
For
Cervical
Cancer
Male Female Others Total
Thoubal 30 24582 40409 2603 67594 8399 15162 11655 10801 6710 2304
Chandel 19 11055 15756 232 27043 1406 13761 11446 6570 3323 677
Ukhrul 13 33 31 0 64 1 248 43 2 6 0
Imphal
East
47 33929 56246 259 90434 6950 31484 25322 26074 15997 1864
Imphal
West
35 41797 67670 289 109756 7097 28905 24910 24896 13847 3342
Senapati 21 12363 17371 61 29795 2164 11803 5818 3512 2017 91
Bishnupur 22 15626 28394 667 44687 4015 15607 10745 9168 6002 228
CCpur 17 5274 7784 216 13274 1128 6850 6518 5739 3152 1250
Tameng-
long
7 2153 3493 90 5736 222 2001 1334 317 264 0
TOTAL 211 146812 237154 4417 388383 31382 125821 97791 87079 51318 9756
Cumulative report of performance of AB-HWC in Manipur: 10.10.2021
In FY
2020-21:
Manipur
ranked
25

45. Some activities by
HWCs of Manipur:

46. Awareness on Breast CA
month
World hospice day by CHO HWC
Heikhrumakhong, Imphal East
Fit Health Worker Campaign launched in
Manipur: 2nd Oct, 2020 to 23rd Oct, 2020
World Mental Health Day observation

47. Manipur gets its first Transgender Health and
Wellness Centre at JNIMS
March 25, 2021
• PPP between India and
the US
• 1st of its kind in the NE
India
• Consists of two units
 Help desk inside
JNIMS
 Wellness centre
located across the
JNIMS building

48. ACTIVITIES

49. Before After AB-HWC
Selective primary health care Comprehensive primary health care
Focus on reproductive age group Life cycle approach
Limited availability of medicines,
OOPE, ↓ treatment adherence
Medicines & diagnostics at nearest
HWC, follow up at community level
Low utilization of vast network of
SHCs & PHCs
SHC/PHC transformed to AB-HWC
ensures CPHC
Limited HR at SC level 1 CHO at SCH-AB-HWC to lead
No gate keeping function at 1◦ level More cases resolved at 1◦ level →↓
overcrowding at 2◦ & 3◦ level
No access to tele-health Referral linkages via teleconsultation
Manual reporting & monitoring Standardised digital health records
Limited focus on wellness component Wellness activities: Yoga

50. HMIS:
5th April, 2021

51. Communitization
State
Health
Society
District Health
Society
Facility level: CHC/ DH:
Rogi Kalyan Samiti
AB-HWCs-PHC/ SHC:
Jan Arogya Samiti
(JAS)
Village level (rural): VHSNC
Slum (urban): MAS
Jan Arogya Samiti
(JAS)
Quality service delivery (IPHS,
NQAS, KAYAKALP)
Health promotion: multi-
sectoral action
Grievance redressal: patient
satisfaction survey
Social accountability exercise

52. Quality assurance Quality healthcare’ is one of the motto of the scheme
National Heath Authority (NHA) has collaborated with Quality Council of India
(QCI) to use their well established systems, skill set and credibility to start a quality
certification process

53. PPP
Jan 2020, NITI Aayog: PPP model to link pvt. medical
colleges with district hospital
‘User fee’ charges
•Management contract
•Purchasing of services
•Build, operate & transfer model
•Co-location model
4 PPP models

54. Digitalization of health care
Launched on 27th September 2021
Ayushman Bharat Digital Mission (ABDM)
AIM:
To develop the backbone necessary to support the integrated digital health
infrastructure of the country. It will bridge the existing gap amongst different
stakeholders of Healthcare ecosystem through digital highways.

55. ABDM
Ecosystem

56. Buildin
g Blocks
“Think Big, Start
small, Scale fast’
Health ID
Healthcare
Professionals
Registry
(HPR)
Health
Facility
Registry
(HFR)
Health
Records(PHR)
Standardize the process of
identification of individual across
health care providers
Comprehensive repository of all
Healthcare professionals involved in
delivery of health care services across
different systems of medicine
Comprehensive repository of health
facilities of nation across different
systems of medicine
E-record of health information on an
individual conforming to nationally
recognized interoperability std. & can
be drawn from multiple sources

57. ABDM
Proposed
Architecture

58. November 2019, eSanjeevani AB-HWC implementation was initiated under
Ayushman Bharat Scheme of Government of India

59. Manipur CM launched ‘Covid-19
Vaccination Express’ on 11th Oct, 2021
• State Gvt. initiative in partnership with
CARE India, an international non-profit
organisation working on Public Health
• To provide vaccination delivery at
doorstep
• Fifteen vans, equipped with all required
facilities and 20 trained staff were
dispatched to the Imphal West district

60. Project Swaraksha: 22nd May, 2021
Large countrywide campaign aimed to solve 'Vaccine Hesitancy' in Rural India

61. Project Swaraksha: 11th Oct, 2021 launched in Manipur
In partnership with USAID-NISHTHA
20 villagers counselled in
Manipur

62. Conclusion
Reform is a cyclical process
Success of health sector reforms lies
with how the process is to be applied
and by whom, rather than on how
the contents are formulated

63. Way
forward for
effective
HSR
Incentive
system to
states
Taxation
Regulation
of pvt.
Sector
Risk
pooling
Strengthening
HMIS, Social audits,
community
monitoring, capacity
building,
prioritization, cost-
effective policy
Effective
decentra-
lization
Increased
public
spending
on health

64. References
1. Wamai RG, Ph D. Reforming health systems: the role of NGOs in Decentralization – lessons
from Kenya and Ethiopia.pdf (application/pdf-object). 2000;(1998):1–19. Available from:
http://www.istr.org/conferences/barcelona/WPVolume/Wamai.pdf
2. NITI Aayog. Investment Opportunities in India ’ s Healthcare Sector. 2021. 1–44 p. Available
from: https://www.niti.gov.in/sites/default/files/2021-
03/InvestmentOpportunities_HealthcareSector_0.pdf.
3. Ministry of Health and Family Welfare. Towards Universal Health Coverage: Ayushman
Bharat Health and Wellness Centers. A compendium of Health and Wellness Centers
Operationalization. 2020. Available from: https://ab-
hwc.nhp.gov.in/download/document/Towards_Universal_Health_Coverage_HWCO_14_12_2
0_for_web.pdf
4. NITI AAYOG. Guidelines for Public-Private Partnership for Non-communicable Diseases
[Internet]. 2019. Available from:
https://www.niti.gov.in/writereaddata/files/document_publication/NCD-PPP-GUIDLINE-
BOOKLET.pdf
5. Ministry of Health and Family Welfare. Guidelines for Jan Arogya Samiti. Ministry of Health
& Family Welfare G of I. Ayushman Bharat- Health and Wellness Centres. Minist Heal Fam
Welfare, Gov India [Internet]. 2019; Available from: https://ab-hwc.nhp.gov.in/home/aboutus
6. Ministry of Ayush | Home [Internet]. [cited 2021 Oct 13]. Available from:
https://dashboard.ayush.gov.in/
7. National Health Auhtority. Ayushman Bharat Digital Mission. Official website Ayushman
Bharat Digital Mission [Internet]. [cited 2021 Oct 13]. Available from:
https://abdm.gov.in/home/ndhm

65. THANK YOU