Health Sector, State and Decentralised Institutions in India

Shailender Kumar Hooda

• Publisher: Routledge India
• Year: 2021
• Print ISBN: 9781032332420
• eBook ISBN: 9781000456929
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Infrastructure
• Index: Politics & International Relations

This book describes the transition in Indian healthcare system since independence and contributes to the ongoing debate within development and institutional economics on the approaches towards reform in the public health system. The institutional reform perspective focuses on examining the effective utilisation of allotted resources and improvements in delivery through decentralisation in governance by ensuring higher participation of elected governments and local communities in politics, policymaking and delivery of health services. It discusses the economic (resource) reforms to explain the relevance and expansion of state interventionism along with its influence on the health sector, accountability and allocative efficiency. The author also explores the connections between neoliberal thought and privatisation in health sector, and examines the greater role of insurance-based financing and their implications for health service access and delivery. The book offers ways to address long-standing systemic and structural problems that confront the Indian healthcare system.

Based on large-scale surveys and diverse empirical data on the Indian economy, this book will be of great interest to researchers, students and teachers of health economics, governance and institutional economics, political economy, sociology, public policy, regional studies and development studies. This will be useful to policymakers, health economists, social scientists, public health experts and professionals, and government and nongovernment institutions.

1

Health system dynamics

Evolution of health policies in India

DOI: 10.4324/9781032108438-1

Countries across the world have adopted different approaches to address the health needs of their population and health promotion, and prevention and control of diseases. This is generally guided by their own historical traditions, political and social contexts, cultural value systems and ideologies (Hsiao, 2003). The industrial state and societies have different lifestyles than the developing ones; therefore, prevalence of disease varies considerably. The historical pattern around the world reveals that healthcare system in Western industrial states and societies emphasises largely curative aspects, being limited to health services in the hospitals, medical practice, and pharmacies based on medical technology. Preventive care (prevention of diseases) has relatively little place of value in those economies (Fisk, 2000). Their medicine apparatus in most cases is unaffordable and unfavourable with regards to price and utility for developing countries because of high difference in prevalence of disease pattern (Ourworldindata, n.d.). The majority of the diseases that are prevalent in developing countries are preventable in nature. The primary healthcare system, therefore, is found to be more prevalent in developing nations. In practice, the industrialised/wealthiest nations have adopted robust healthcare systems, while it is too disorganised in many developing countries; whereas the rich get high medical care/attention, the poor have less access to affordable healthcare, and either they stay sick or die or if they seek care have to pay from their own pockets. Interestingly, however, available research tends to suggest that none of the healthcare systems systematically outperforms the rest; however, some performed really better.

The fundamental questions that thus arise are the following. Why do some health systems work better than others? What features of that system contribute the most to produce favourable outcomes? How can policy makers restructure the existing system to achieve preferable outcome? This depends on how a nation has designed its health system and which type of distinct features and components its health system has (Hsiao, 2003). This study elaborates that health system in general have features of: a) financing, b) organisation of service delivery, c) payment mechanism, d) regulations and e) persuasion.

These features have different characteristics (see Rao, 2017).

Financing has four characteristics, namely: a) financing methods (whether healthcare is financed through government taxes (United Kingdom, Spain, New Zealand, Cuba), employer- and employee-mandated social health insurance (United States, Germany, Belgium, Japan, Switzerland, the Netherlands), government-run/national health insurance (Canada, Taiwan, South Korea) or market-driven healthcare financed through households out-of-pocket (rural India, Africa, South America and, to a degree, China), giving a narrative who control the resources and who bears the financial burden; b) allocation of funds (on different components like medical and nursing education, service delivery, creating physical infrastructure or on staffing, rural and urban setting, primary, secondary and tertiary care), which might impact the access and finally health outcomes); c) rationing (insufficient and unskilled professionals who might impact access, equity and quality); and d) institutional arrangement of financing (like centralised or decentralised, through taxes, user fees or insurance, which helps to understand how equitable and fair the system would be and which types of moral hazards and adverse selection problems it would encounter).

Organisation of service delivery means: a) whether there is monopoly or competition in service delivery; b) how efficient the vertical integration of (primary, secondary and tertiary) service delivery is (like the US focus is more on curative tertiary, while India it is on primary care; each one neglects the other side of care); c) ownership of providers – public, private-for-profit or not-for-profit – as ownership describe the kind of care provided, type of patients seen, nature of disease treated and extent of denial of care happens due to unaffordability); and d) decentralisation of health service delivery, which is often considered a good mechanism to ensure that benefits reach the intended and local government can plan better to the need of local people. Its benefits, however, depend on how this concept is conceived and implemented.

Payment mechanism means incentive system like the mode and amount of payment (fixed-budget, fee-for-services, reimbursement, capitation or salary) which impact the behaviour of different actors like the patients, providers and insurers, which in turn can affect cost, efficiency and quality of care provided.

Regulation is generally enforced by government to impose certain boundaries within which the professions have to function or the manufacture and sale of pharmaceutical products and medical devices have to be organised. These are important to ensure patient safety, equity, efficiency and quality and correct market distortions.

Persuasion – whether by governments or private players – can influence peoples’ beliefs, lifestyles, expectations, preferences and behaviours through advertising campaigns and dissemination of information. Persuasion also affects the supply side, justifying governments to regulate and organise medical education as service providers profoundly affect the availability, efficiency and quality of healthcare through the medical ethics and beliefs they uphold (see Rao, 2017).

The health system of any country might consist of a mix/overlapping of these profound features (Hsiao, 2003). The nature of health system evolution, however, is not constant. Its dynamics change over time. It is either guided by growing healthcare needs, changing health profile and burden of diseases (communicable to non-communicable), or influenced by changes in global health policy and advocacy like from a ‘health for all’ agenda to achieving ‘universal health coverage’ targets in recent times. There have been tendencies to borrow other countries’ best experiences to model their own healthcare system, as well. In addition, the macroeconomic conditions and changes also influence the health system dynamics. The healthcare structure in India has an evolutionary and organic history, where the state over time has tried to reorient its approaches while absorbing the changing dynamics of health profile and policies.

India’s state interventionist approach in healthcare

When India became independent over 70 years ago in 1947, the country had several challenges on health as well as on socio-economic fronts. Of the total 36.1 crore population (GoI, 1951), only 18.3% were literate. Female literacy was at 8.86%. Only 1 of every 11 women were able to read and write. While tracking India’s progress in health sector after 70 years of independence, Zodpey and Negandhi (2018) reported that overall life expectancy at the time was 32 years. The infant mortality rate (IMR) was 146 per 1000 live births. Maternal mortality ratio (MMR) in the 1940s was 22.2 per 1000 live births. The country was facing a high burden of communicable disease. The number of doctors across the country was only 50,000 and primary healthcare centres only numbered 725 (Zodpey and Negandhi, 2018). The country had no proper healthcare system. The average per capita gross domestic product (GDP) of a citizen was very low at Rs. 1705 ($81.3) in 1960. This means people had low capacity to pay with high prevalence and burden of diseases, largely the communicable ones.

India constituted several committees to suggest measures to address the prevalence of diseases, as well as to invite suggestions on how the Indian health system should be designed. India tried to follow a principle that health is a ‘public good’. India’s foremost Health Survey and Development Committee encompassed around the principle that ‘nobody should be denied access to health services for his inability to pay’ (Bhore Committee, 1946: 17). After independence, India constituted more than 25 committees to work for a strong public healthcare system. Several committees on health of independent India (like Sokhey [1948], Mudaliar [1962], Chaddha [1963], Kartar Singh [1974], Srivastava [1975] and Joint Panel of Indian Council of Medical Research-Indian Council of Social Science Research ICMR-ICSSR [1980]; see Table 1.1) considering the diseases burden (like diarrhoea, lunginflammations, tuberculosis, malaria, and so on) and mortalities pattern in the country all suggested having a comprehensive primary healthcare system in the public sector. The country launched several disease control programmes at dif...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication Page
• Contents Page
• List of figures Page
• List of tables Page
• List of boxes Page
• List of appendices Page
• Preface Page
• List of Abbreviations Page
• 1 Health system dynamics: evolution of health policies in India
• Part 1 The state as a provider of healthcare services
• Part 2 Institutional reforms: decentralisation in service delivery
• Part 3 New financing and policy paradigms: redefining the role of state
• Index