Devaki Nambiar PhD, Kabir Sheikh MBBS MPH PhD

Health Governance HubPublic Health Foundation of India

4th Technical Review Meeting for the HPHFKH10th October 2011

A team of researchers across our family of institutions in five cities

Core interest in the relationship between health systems governance and social justice

THEME AREASRegulation and stewardshipCommunity action for healthHealth workforce governance

Pharmaceutical policyUrban health governancePublic health philanthropy

As India moves towards Universal Health Coverage…

Sheikh, Saligram, Prasad (2010-2011)

Funding: Nossal Institute

Normative position: Regulation as a means to health equity, health rights, development (Mackintosh 2007)

Approach: Backward Mapping: ‘bottom up’ understanding of field level phenomena generate policy needs (Elmore 1982)

Process:

Quality of careQuality of care

Accessibility of care

Accessibility of care

Conduct of providers

Conduct of providers

Costs of care for users

Costs of care for users

Regulatory targets identified from in-depth literature review on LMIC ‘mixed’ health systems (Oxfam 2009, Nishtar 2010)

Development of tool for policy mapping and gap analysis of policy design (relative to target) and implementation (relative to design)

Pilot study in two states in India

MP

Delhi

Delhi Madhya Pradesh (MP)

Cost of Care RSBY and government subsidies to private hospitals both aimed at reducing costs of private care for EWSDo not address the high incident costs in public facilities, or financial protection of non-EWS. No direct control of care costs, no regulation of competition.

No known laws or regulatory policies for the curtailment of costs for users of health care, other than recently introduced Janani Sahayogi Yojana (Mothers’ Assistance Scheme)

Quality of Care

No credible regulatory mechanism to limit practice by unqualified providers. Absence of credible community-based forum for grievance redress.

Absence of credible community-based forum for grievance redress.

Conduct of Providers

Accessibility of Care

Not addressed through act or policy Variable workforce distribution, only mandatory rural service, no incentive based policies

Delhi Madhya Pradesh (MP)

Cost of Care Information asymmetries impede uptake of social insurance scheme, also lack of stringent regulatory component. Reduced investment in regulatory capacity of relevant departments impedes enforcement of EWS free-bed condition for hospital subsidy

Clinical Establishments Act, PNDT, MTP: Implementation is partial due to personnel constraints problems of inter-departmental coordination, affects relationships with hospital owners

Quality of Care

Multiple contestations of NHRA have diluted content. Partial implementation due to personnel constraints and organizational inertia, active resistance of medical fraternity

Self-regulatory council’s commitment to disciplinary functions, made problematic by closeness to associations who oppose regulation.Engagement with additional tasks such as reducing quackery greater than performance of disciplinary roles.

Conduct of Providers

Councils role less disciplinary, more advocacy for professionals’ rights, medical sanctity

Accessibility of Care

Health authority subordinated to urban development authority in determining location of new hospitals

Implementation of rural medical bonds hampered by extensive contestation by doctors’ groups, problems in coordination between government departments involved in placements

Sheikh, Gilson, Bennett, others (2011)

Commissioned by PLoS Medicine

SYSTEMS FUNCTIONS

Systems defined on basis of their utility, problems mainly relate to efficiencyDecisions are concentrated, flow in one directionPolicy content not problematized

E.g. WHO ‘building blocks’

Systems Human Resources, Finance,

Medicines & technology, Organizational structure,

Service infrastructure, Information systems

Outputs

Outcomes

Policy Decisions

Systems ‘Software’Ideas and interests,

Relationships and power, Values and norms

Systems ‘Hardware’Human Resources, Finance,

Medicines & technology, Organizational structure,

Service infrastructure, Information systems

International

National

Subnational

Local

ARENACOMPLEX AND SOCIALLY CONSTRUCTED

Decisions are diffused, relationships are non-linear‘Software’ critical to health systems performanceProblems (and solutions) are related to (understanding) complexityShaped by particular politics, culture, discourse (and not others)Solutions within and beyond health systems

(e.g. Frenk 1994, de Savigny and Adam 2009, Lambert 2006, Illich 1970)

Thank you

devaki.nambiar@phfi.org