Health Sector Reforms In Andhra Pradesh
Health Sector Reforms In Andhra Pradesh
Health sector Reforms in Andhra Pradesh
A review on Health sector reforms in India The health sector reforms in India were started way back in 1970s .The Govt. of India identifies the need HSR and stated in the eighth five year plan. The Eighth Five Year Plan (1992-1997) was the first plan document to state the need for re-structuring of economic management systems, following the macro developments of the 1990s. During this period in the health sector, the concept of free medical care was revoked and people were required to pay, even if partially, for the health services (1). The Ninth Five Year Plan (1997-2002) emphasized the need to review the response of the public, voluntary and private sector health care providers as well as the population themselves to the changing health scenario, to reorganize health services to bring about greater efficiency and effectiveness and to introduce health system reforms to enable the population to obtain optimum care at affordable cost The Ninth Plan sought to increase the involvement of voluntary, private organizations and self-help groups in the provision of health care and ensure inter-sectoral coordination in implementation of health programmes and health-related activities as well as enable the Panchayati Raj Institutions (PRI) in planning and monitoring of health programmes at the local level so as to bring about greater responsiveness to health needs of the people and greater accountability; to promote inter-sectoral coordination and utilise local and community resources for health care(2) .The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary and tertiary level(3). Politics influence health systems in significant manner. The goals, priorities, and the strategies, variations in the commitment are largely decided through the political contingencies. There are competing demands on the health systems. The evolution of the health 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 health system in India is the most corrupt system (4) The Government has taken several steps for improving the public health care institutions and Strengthening the primary health 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 health needs of the people are met One of the major reform initiatives underway is the Secondary Health System Strengthening Project funded by the World Bank in seven states (Andhra Pradesh, Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). 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 health care providers; reduction in mismatches in health 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 health sector reform.(5) In the Indian Constitution, health is a state responsibility. During Adjustment, many state governments in India had recourse to Health Systems Development Project loans from the World Bank for carrying out health sector reforms (HSR), of which one of the key policies has been to raise public spending on health care from the abysmally low levels seen up to then. The Health 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 health, the limited portion of total health 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 health sector, 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 health 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 health-care sector; (iv) to charge user fees for selected services; and (v) to address workforce issues. The Health Systems Development Project initiated in the seven states recognizes the need for enhanced public spending on health and identifies it as the foremost policy reform to be pursued. Nevertheless, such assurances and conditions have not succeeded in enhancing health sector budgets in states implementing HSR. Worse, HSR has not been able to arrest the decline in the share of health 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 health-care spending is bestowed on the states (6).Andhra Pradesh is the first state to go with the HSR. Health sector reforms in Andhra Pradesh The state of Andhra Pradesh 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, Andhra Pradesh 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 Andhra Pradesh was the first Indian state to receive a multi-sector Bank operation – the Andhra Pradesh 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 Andhra Pradesh 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. Health 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 health services is hampered by demand and supply side issues, including poor health infrastructure and staffing.(15) The reform history in health sector in the State can be traced to Andhra Pradesh First Referral Health System Project, one of the first World Bank aided health 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 health care as one of the component.(7) The priority reforms focus on improved access to quality and responsive health services, strengthened governance and management in health sector, improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems.(15) The government of Andhra Pradesh [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for health sector reform: providing universal access to primary healthcare; encouraging private investment in tertiary healthcare; focusing on specific programmes to promote family planning; focusing on improving health levels in disadvantaged groups and backward regions; ensuring a strong prevention focus; enhancing the performance of the public health system; and formulating a state information education and communication (IEC) programme to broadcast information on preventive healthcare.(13) The Government of Andhra Pradesh is embarking on a major health
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