Strengthening Public Health Systems

Strengthening Public Health Systems

A Research Programme and a Call for Action.

1.      The question and the task of strengthening public health systems must be posed at the right level- at the frontline of what has been most recently attempted, [1]the constraints faced and the further knowledge, innovation or institutional change required for further change or progress. Merely lamenting the obvious, or discovering the commonplace or proposing the existing formulations[2] does not help move forward.

A system delivers what it is designed to deliver- neither more or less. The causes for poor efficiency and effectiveness of the public health systems must be searched for in its design. A framework of understanding that sees the problems as “good plans that are poorly implemented” either due to the inherent nature of public enterprises, or due to weak capacity or due to poor motivation of the workforce- are all tautologies. They are non-answers to the problems that impede the formulation of appropriate questions.

In this note we list a number of problematics- or problem statements- which describe the constraints. The “problematic” term is used to denote a problem that lies embedded not only in a social, historical and health systems context, but also whose solutions lie embedded in a theoretical or ideological framework. Thus in certain contexts or frameworks the problems could even be denied. Thus for example how do you “retain doctors to work in remote areas” seems a straight-forward problem- but what was possible in the sixties may not be applicable now- and the solutions may vary between Himachal, Bihar and Tamilnadu. One ideological framework may see compulsion as a solution, another may see incentives and third may see alternative cadre and a fourth may see private partnerships or even corporotisation. Thus a simple notion of every problem having a neat solution would be simplistic.

 Having defined the problem the note suggests a possible solution that “we” as activists working for change choose to support. These are usually “ incremental innovations” through which the “problem” could be overcome- our current tentative and consensus solution to the problematic. In doing so, we draw upon programme evaluation and health systems studies that have been done by NHSRC and also refer to a few other studies which have concerned themselves. But we accept that much more studies and evidence is needed before one can test alternative approaches and be sure of our own. That is why this could also be used to define a research programme.

Any proposal for change we make must consider alternative scenarios. This helps us not only to negotiate or even champion the case for “our” position, but also to understand our own position better. Therefore for every incremental innovation we suggest, we also consider what is the “existing answer” – a counterfactual position- as if there was innovation. We could have called in the status quo position, but that is not correct since votaries of this position are serious about improved administration and this is a legitimate point of view. So we refer to it as the “No Innovation , Only Improved Administration” position.  We also then examine what is the answer that emerges from a “managed care” alternative. This could be appreciatively called a “disruptive innovation.” Some of what we attribute to this managed care positions, is derived from the HLEG report, and some from the steering committee report, and some are our own extrapolations of the same. It represents the solutions as emerging from a particular framework of what is best described as “managed competition”.  Let it be stated upfront, that this is not what HLEG is saying- and we are not attributing what is presented here as the managed care position to the HLEG.  It will be noted, that in each case, that it is not as if the incremental solution is correct and others- the “no -innovation, -only -improved -administration” or the “managed-care- option” is  wrong. In fact each of these three positions could appropriate elements of the other position. This is just to map the problems out and set a research agenda. To the extent one has a shared framework of how change happens and the direction of desired change, then it becomes a call to action as well.

2.      We list below the set of problematics that this note shall address:

                    i.            District Planning did not emerge as a creative tool  in the XIth Plan period. The central problem was that it did not function as the effective guide to resource allocation. It was not also participatory enough. It was not based on village and block level plans and even household surveys as was intended.  Why is this so and what is the proposal to overcome this.

The State Health Society- state programme management unit did not provide effective leadership or accountability. They were parallel structures to the directorate of health services, and the latter was weakened. Efforts to give powers to the directorates of health services were also tried- but these came to naught. Similarly the State institutes of health and family welfare are weak and are difficult to strengthen.  State Health Systems Resource Centers have been difficult to create or sustain.

A public health cadre is required. There is a need for developing a leadership sensitized to public health. Doctors as a rule tend to be too clinically oriented and make poor managers, but they do not like to surrender their positions in authority. There is a belief that PSM postgraduates or those trained in public health management, if they occupy, public health positions would make a difference. But there are not enough of them around.

The NRHM goal was for all sub-centers, PHCs and CHCs and DHs to achieve a set of service guarantees. The actual achievements are far below this. Firstly in practice only RCH service guarantees were attempted. Secondly even on RCH, only one in 3 PHCs reached 24*7 level functioning. Though almost all CHCs reached the level where PHCs were supposed to reach, very few reached the levels of an FRU which they were supposed to reach. And third even in RCH, the actual skill level and range of services provided are less.

Almost no facilities achieved IPHS. The rate of improvement of facilities to reach IPHS is very poor.. Almost one in 5 CHCs reached the level where CHCs were supposed to reach in terms of service provision.

Quality of Care in public health care facilities is a problem.

Human Resources -1: It is difficult to find doctors and nurses to work in rural and remote areas.

Human Resources- 2: Basic workforce management is appalling. Most of those who are posted absent themselves and their motivation, work performance and attitudes are poor. Promotions, transfers, postings, irrational deployment of staff and so on- it’s a mess.

Human Resources-3 There is a need to ban private practice by government doctors. But this has been a very intractable problem.

A large part of the funds given to public health systems are returned unspent.

Accountability has been very weak and difficult to ensure. This is despite the accountability systems in place. In particular the district health society and state health society system does not seem to be ensuring this. Corruption is endemic.

Despite commitment, there are no emergency medical response systems in place.

Sustainability of the ASHA programme is a problem. There is a growing demands for regularization and salary, as there is a persistent problem with skills and outputs, and there is a persistent problem with role clarity. Clearly some form of CHW is considered as required, but there is no agreement on what is required.

Village health and sanitation committees are very varied and performance and outcomes.

Health Information Systems provide poor quality data. Each vertical programme has its own health information system, and each department has theirs and they do not share between them.

The principle of integration of all vertical programmes is well known. However integration of the vertical programmes has eluded us. The NRHM failed to achieve this.

The principle of action on social determinants is well known, but actual forward movement on this has been limited.  There has to be clarity about what action is being required and of whom.

There is a requirement for technology innovation in a wide number of areas, since available technologies- drugs, diagnostics, devices. are not adequate or appropriate for the purpose. But how does one solve this.

There is a huge problem on choice of technology and technology uptake in public health systems. One example is vaccine choice. Another is inclusion of a drug or device in a standard protocol, like the inclusion of co-trim in CHW protocol or iron sucrose in treatment of anemia in pregnancy. Unfair criticism could disrupt programmes, on the other hand there is a need to prevent corporate pressures. Policy paralysis in the face of constant controversy is also a problem. How does one overcome this.

The private sector has 80% of the doctors, and 30% of the nurses and provides 80% of outpatient care and 40% of inpatient care. But there has been no serious effort to engage with it or harness its potential. Why this failure – though it was very much part of the NRHM.

3.      There could be many more problematics- but we could start with these. In choosing to focus on these 20 problems, we are not undermining the big two- need for more investment and need for better governance and management. These are obvious, and there is a role for getting it right. The focus of this note is on the failure to use current levels of investment optimally. Also, an assumption is made, that if over 70% of the units fail to get a programme outcome right, then we must examine the design, not blame the implementors. One principle of analysis is that “Wars are never lost by bad soldiers, they are always lost by bad generals.” This is an useful way to think about problems. And that does not just mean a weak officer in command- it means that there is something wrong at the level of systems design. Typically, anything on our problematic list has appeared in at least three or four five year plans with various solutions for the same, and have been either dismissed as operational issues or rhetorically re-stated in a number of commission reports.

When we propose a solution, what we offer is a tentative “ state of the art” answer which is in the nature of an incremental innovation, that is immediately actionable.  Because a government has always “ got to act”. As each proposal for action, gets accepted and rolled out, it would generate further questions and give rise to new problems. So these are dynamic questions, constantly evolving- defining a domain for research and a domain for action- without admitting a final answer, now or ever.  Many of the answers offered here would require more evidence to support. The difference between fact and evidence and the difference between evidence and opinion is not always clear. And given the way tacit knowledge at the implementor level works, all unsupported opinion cannot be dismissed, though one must still call for evidence to support contentions. Thus every call to action, is implicitly also a research programme. But the end point of our research programme cannot be just knowledge generation, or the construct of ways of thinking or models of analysis, but the actual level to which research outcomes lead to change.  Thus the research programme is only a part of a call to action.  We also define “change” as change towards better health outcomes, more health equity, and more democratic  decision making- each as ends in themselves.

That is why this note should be seen equally as a research programme and as a call to action. [3]

Part II:        Examining Each of the 20 Problematics:

Problematic- 1: Resource Allocation and the District Plan:

1.      Problem statement -1: District Plans are one of the key strategies of the NRHM, that were taken to scale, but which did poorly in terms of positive contribution . Much of general administrator and civil society concern was with process- the general administrator requiring formats and standardization, and civil society requiring more consultation and participation. There was considerable investment in capacity building for district planning, and even if every district did not get it right, some states and districts did do a very good job. However nowhere did funds flow according to district plans- and the more participatory the planning had been the more the disappointment. The central issue is really of responsive resource allocation to match the district plan.

If district budgets were sanctioned according to each line item, and further these were specified in the format- it left very little room for innovation and local variation. Further the rate of movement of each line item varies and often acquires its own autonomy. Thus in one place equipment would be purchased, but HR would not be in place, or infrastructure would come up, but supplies would not match it, or case loads would vary across facilities, but untied funds would be the same to all – and so on. The administrators contention was that if given in an un-tied fashion to the district society there was either the lack of confidence and capacity to spend it appropriately, or the chances of mis-spending and a signal to enhance rent-seeking.

Where participation and local planning effort took place, they came up with different priorities for similar problems and similar actions in different situations. The budgets they proposed got modified, if not ignored, at the state level. The budgets and activities were further modified at the national sanction of PIP process, which then got modified once more at the state level, during post sanction allocation to the district. What budget and activities the district eventually got a sanction for had no relationship to what it asked for. Also there were problems with unit costs, which made aggregation of district budgets into state budgets impossible. Some efforts in the last two years to ensure a post budget realignment and an installment based release of funds to districts, instead of different line item based releases made at different times- did help. But these were insufficient and in most states, given this disappointment, the level of district planning actually declined. The district plan document failed to be even utilized as a reference point for either programme implementation or review.

The process of making district plans each year is also exhausting. Also it does not promote innovations, for there is no certainty of a longer term financing to support innovation. At any rate most innovations are received with skepticism and tend not to get approved- but this is often justified, as innovations are more often that not very weakly designed.

The solution lies in an incremental innovation. Instead of sanctioning the district budget by close to a 100 line items- reduce sanction to only six heads- and linked closely to measurable outputs in terms of services delivered.  These heads would be broadly one capital head with five revenue heads.

                                        A.            Capital Head: Facility Infrastructure and Major Equipment: This is paid from a separate capital fund pool- as it has a longer cycle time of expenditure and slow expenditure on this account, should not hold down the entire process.

Revenue Heads

                               i.            Community Processes- ASHA, VHSCNC, VHNDs, community monitoring, NGO roles and BCC.- paid to the district on a per capita population basis- which can be used efficiently and innovatively- for preventive, promotive action, changes in health care practices.

Facility Development- Human Resources- salary payments including any payments for ASHA, sub-center staff. This is against service delivery outputs. District plan specifies what is  the baseline services available and what is the expected increase in services linked to additional human resource deployed in each facility.

Facility Development and Programme Management -Supervision, Maintenance and Management.- could be computed as a factor of the number of facilities which are part of the district integrated care network.

An Untied District Pool- for a) purchase of services from private sector, and b) reimbursement to operational costs and provider incentives to public sector units and c) drugs and diagnostics- though this is paid through state level drugs supplies corporation- this again paid on a reimbursement basis D) emergency response and patient transport system- this again through an agency/agencies procured at the state level and reimbursed on a monthly basis.

 Demand Side Financing- on per case basis- this is only for JSY and for sterilization compensation. (this exists- too much of a problem to remove it- but one could allow districts the option to move this fund into the supply side as part of the operational pool.

The district plan would decide the facility strengthening plan- essentially listing the facilities and defining what assured services each would provide, such that within the districts all essential health services are provided. (Which is not the same thing as saying every sub-center, every PHC and every CHC would provide IPHS level services). The district plan therefore specifies the current package of services available in that facility, the package of inputs and activities and budget that is required, and once these are available, the revised package of services that would be available. 

Defining service packages: Since too many variables and too many packages would be difficult to understand, construct, finance and monitor- we suggest only four or five packages, each of which is categorized into three or four levels of services. Thus we could have a RCH package, an emergency and trauma care package, a communicable disease package and one or two non communicable disease package. We could allow a dental health package and mental health package separately.  Thus RCH there is a level- 1, level 2 and level 3 facility package. Individual facilities could specify exclusions- for example the facility could define that mother to child HIV prevention ART is not available- but unless so specified it is assumed that the entire package is available. Normally a level 3 service is what currently a specialist can provide-( or a short course multi-skilled MBBS doctor). A level 2 service is what a team led by an MBBS doctor, perhaps with some extra training is qualified to provide- but the focus is on a team. A level 1 service is what a mid-level care provider- a nurse or pharmacist or AYUSH doctor or a MBBS doctor can provide. Some support is needed.

Community participation would have meaning as a) they could look into and ask for inclusions into  the package of services and b)which facilities are prioritized for provision of these in a given time frame and c) there is some space in the fund provided in BCC, community processes etc, for some limited innovations.

There is a considerable role for institutional innovation in how the rules are made in each district to use the district untied pool fund for reimbursement in these four areas as specified above.  Well managed it could lead to considerable “diversification” and experimentation. (One needs to study concrete examples of how such innovation has happened under NRHM and also look at innovation theory to understand this).

Village plans do not add up to a district plan- and much less do household plans add upto a village plan. Just drop that idea. But some village plans are useful to understand health care priorities, issues of marginalization and constraints. Post sanction, VHSNCs can use untied funds creatively- but given the size of the fund- too much cannot be expected.

There is a major problem on epidemiology based planning, let alone  burden of disease estimates. One of the reasons all district plans currently look the same is that there are no meaningful estimates of the disease burden. The international estimates are based on RGI causes of death 2004 and 2008- and there is something seriously wrong with the way they have calculated it. For example the burden of disease due to pertussis is higher than due to malnutrition and anemia combined. Simple epidemiology estimates of incidence and prevalence, with some cost of care added in, may be preferable- to rank the health care priorities. For after all the only decision district plan would need to take with such information is to add it into the community processes package and into the facility package appropriately.  But we have to find out how to do this on a regular basis and at the district level.

No Innovation, only improve administration (The Status Quo) Position:

Such financing will be difficult to monitor and to account for. Audit would have problems, and we cannot be responsible for many sub-optimal decisions that districts would make with the funds. Rent-seeking of the UP variety would increase.

Better to insist on improving the formulation and sanction of a budget which specifies activities and budgets by line items. And monitoring, including community monitoring, can be used to ensure compliance.

The Managed Care Position:

Hand over the task of making such a district plan to an integrated district level care provider. The role of the state is to procure by tendering or other means, a HMO to undertake this role and pay that agency at say Rs1500 per capita. Thus in a district of 10 lakh population, we give the HMO, Rs 150 crores per year. You also give them standards of care that they must adhere to and monitor this. The HMO called here as the “integrated care network” will achieve these standards of care, at much level cost and much greater efficiency- and that is because they are driven by seeking a sustainable profit from the bottom of the pyramid. (what HLEG calls rewards and penalties). They will also advertise and positively project their achievements, in a way that governments cannot do, and so politically the risks would be low. Any sensible HMO  would have enough role for NGOs as well. In such a strategy of “marketing” absorption of community voices is quite possible- and can be incorporated into the promotion (of HMO) strategy. The drive to innovation and good performance rests upon the state being able to set up a competition between a limited number of provider networks. If there are competing providers, one can get better prices, and the government need not worry about fixing the price too far- as the market and competition would guide in this. It would also mean that it could eliminate those providers who do not achieve standards. It would have been impossible to monitor each sub-center and PHC, but it is possible to monitor an integrated care provider, since only a sample of facilities needs to be seen. Also because the state is managing an independent HMIS, the facility is visible at all times.  If the sample shows that the HMO is not achieving standards, the contract can be terminated and one can re-tender!!

HMOs can bring in the technical assistance to prioritise where they would locate their facilities and by estimating disease burden what services they would provide. Thus they need- at the periphery some hybrid of the current sub-center and PHC which shall maintain a family health record for each family and individual and provide primary care- also known in this language as pre-hospital care and above it have three to five hospitals. This would rationalize facilities and manpower deployment most efficiently.

The first call for a provider in the integrated network would go to a public hospital, but there would be other choices, and if over a time period, the public hospital loses out, so be it. But what is expected is that especially in most rural areas and primary care levels, the public facility would remain the mainstay and the district hospital would also remain. In-between two or three hospitals at the SDH level would rise, which are private sector owned, and these would set the pace.

Problematic – 2:

1.         Problem Statement: The State Health Society- state programme management unit did not provide effective leadership of accountability. They were parallel structures to the directorate of health services, which were weakened. Efforts to give powers to the directorates of health services were also tried- but these came to naught. Similarly the State institutes of health and family welfare are weak and are difficult to strengthen.  State Health Systems Resource Centers have been difficult to create or sustain.

2.         The incremental innovation in this area would be to require the state programme management unit to have a number of working groups or divisions within which corresponding officer of the directorate is either placed in charge, or at least a member of the group- depending on the relative competence and seniority of whom we have in these two organisations. A commissioner of health or secretary ( different from principal secretary) is the mission director. Each para-statal agency has a clear TOR, a coordinating mechanisms and a HR policy.

3.         We could move towards the director of health and family welfare services as the mission director. This was tried in the early years of the Mission and failed quite clearly. But if a public health cadre emerges and if it there is a pool of senior officers with adequate experience of policy work, administrative work and district management, then this would be possible and better. But they would still need the state programme management unit, and the seven para-statal organisations. This is explained next.

4.         The current structure of the directorate is an administrative structure, where one has a pyramid of deputy, joint and additional directors of health, each of whom are attached to a section- with a section officer and a set of clerks. There is no administrative space by which any of these officers can construct any team under them, especially not a multi-disciplinary team. This additional personnel and teams that are required, emerge in a large variety of para-statal organisations. In Nirman Bhavan itself we have upward of 200 to 400 consultants paid for by development partners who provide additional technical assistance to the officers there. They are there because though there is unspent administrative fund at the national level, the administrative space to bring in such skills or numbers is not there. Under current rules, one has to create a new administrative post like another assistant commissioner or joint director- which is not what we want- since we want a junior person. Or if it is not a doctor, we could have clerical staff !!! One could, one must reform this structure – but this has to be done across the board- for every department, including the ministry of defense has such problems- and is the subject matter for an administrative reforms commission.

4. The chairperson of these bodies is a senior person- but even he/she must be held accountable for a) holding the meetings once every six months or once every year, whatever frequency specified b) signing off on the detailed agenda papers including a review of the progress of the programme and minutes of the meeting. Must be “held accountable” is  in administrative terms by a state and a central officer higher than them in seniority.

5.  Many state health systems resource centers were formed as a team of consultants directly reporting to the mission director. They became extra hands to the team- not extra minds. The environment for internal capacity building, team building, institutional memory, continuity past changes of reporting officers, clear long term work allocation and deliverables- were all difficult if not impossible to create unless you had distinct bodies with an internal dynamic and an innovative HR policy. Also there was a need to understand the difference between knowledge management and programme management, and the need for change management organisations.

No Innovation- improve administration (Status Quo position):

1.A general administrator would think the solution lies in strengthening the hands of the mission director- having the commissioner as mission director would be the big solution. The second is to question the need for multiple organisations, and seek to keep all the powers and the units as reporting directly to the mission director. At best a SIHFW is acceptable.

2. A directorate of health services would think that the solution lies in ensuring the funds flow through the directorate. No other para-statal agency is required, and all consultants report directly to officers of the directorate. A SPMU  with director of health services in the chair is acceptable, albeit reluctantly. Consultants hired, and paid for by development partners and given as technical assistants to various officers is desirable. In this view, there is no general problem of work efficiency or organization, it is merely a problem of lack of inputs- salaries, equipment, infrastructure, human resources. And of course it is a problem of the general administrator- who does not understand, but has all the powers.

The Managed Care Option:

The existing state health society or directorate- whatever- it does not make  a difference, is entrusted with the task of running the public hospitals and health facilities- the hospital superintendent role.

A separate corporation like TNMSC is set up exclusively to tender and procure health management organisations to run integrated care networks in the district. Their job is purchasing care- either from the state health society managed facilties or from the private agencies.

A third independent state level body acts as regulator, evaluator, accreditor etc.

By separation of these three roles of the government- as provider, purchaser and regulator- into three separate bodies, we solve the problems of the state leadership.

Problematic -3

1.      Problem statement 3. A public health cadre is required. There is a need for developing a leadership sensitized to public health. Doctors as a rule tend to be too clinically oriented and make poor managers, but they do not like to surrender their positions in authority. There is a belief that PSM postgraduates or those trained in public health management, if they occupy, public health positions would make a difference. But there are not enough of them around.

There are many ‘programme theories” of what a public health cadre is and what a public health cadre does. In the HLEG view- there is a separate public health cadre who looks at preventive and promotive aspects and a separate health systems management cadre who looks after administration and management. In the ministry view, the public health cadre is also a programme manager. In this view- the ANM, male worker and supervisors, and the PHC MO- that is most of those with non clinical functions are all part of public health cadre. . This views is inspired by the view that doctors make poor managers. Also that public health or public health management training makes for better management. There is no evidence behind any of these points of view- and indeed there is anecdotal evidence to the contrary. The nearest thing to an experience is the TN public health cadre model which works somewhat and therefore in an incremental approach we start with this, take note of its weaknesses and cover it as best as we can.

In the TN model we have some of the PHC MOs and all health officers as entry points into the cadre. After a stint in these positions they have to get public health qualified- and then they get posted as deputy director of health services- which is a post that commands all the public health staff. In effect it is like a CHMO except that CHCs, SDH and DH is not under them. The hospital superintendents of these hospitals come under a joint director  and they are all part of the directorate of medical services. Thus the directorate of health services from top to bottom is public health care and the directorate of medical services from top to bottom is medical cadre. There is no private practice allowed for public health cadre, but promotion is rapid as compared to the other cadre and this seems to compensate. Most important this cadre takes pride in public health achievements and in regulatory functions. The weaknesses are that with the hospitals outside the system, public health programmes which are facility based- like RNTCP do poorly and have little support.  Coordination is weak between the two services at the district level because of parallel command structures. Even their information systems are separate which design features which prevent sharing of information. And finally no non-doctor can make it to either administrative structure.

The incremenatal innovation we need to propose is as follows: About half the posts of medical officer PHC, and all the posts of health officer urban area, block medical officer and a post of chief medical officer- public health, be reserved for officers recruited into the public health cadre. The ANMs, male workers etc come under this command structure. In parallel, the hospital supt of SDH and DH come under a hospital management cadre which reports to the civil surgeon or head of the district hospital. One could have a joint chief medical officer above these two reporting to a combined directorate of health services or one could leave it as two chiefs in the district reporting to two directorates- one of health services and one of medical services- which is the TN model. We however recommend the former option, for a unified command at the district is useful and the cadre of the district hospital and SDH is required for many public health programmes.

Like in TN all who opt for this public health cadre have to get a public health qualification within two to five years- and this is essential for promotion. But unlike in TN, a hospital superintendent, can become the chief medical officer and rise in a common directorate cadre. This allows for specialists with seniority who want to enter administrative work, to do so. Formal public health qualification is not a must.

In contrast to the TN model, non-doctors, but with an MPH can join as programme managers in block and district levels, and then become a part of the cadre. The TN model has no space for non-doctors. Also the BMO in the TN model is part of the medical services cadre- and not the health services cadre. There is a question of how high this entrant can rise- may require a doctorate for state leadership roles. Again the second sub-center health worker could be a B.Sc in public health- who could get a masters to play district level roles, rarely rising above this- perhaps a few, by the end of the cadre.

All those who enter the top two levels at the state directorate, should have worked for at least three years on policy development as part of parastatal organisations, or worked with consultancy organisations or international or national policy forums. By creating a number of equal posts in seniority at the top level, most of which are of advisory character one would allow a selection from at least five top qualified persons.

The restructuring of state cadre for leadership is incentivized by the MOU conditionality mechanisms, states which do this being eligible for a larger resource envelope.

No Innovation: Improve Administration:

None of this is needed. It depends on the individual honesty, integrity and competence of officers. Such changes are difficult to implement- and center should not get into dictating this. Leave it to the states.

Managed care Position.

Public health cadre is most required. This should be outside the HMO and integrated care network- which provides curative care. The state health society and district health society, other than being providers of curative care-( which we can expect them to be phased out of) must provide these preventive and promotive functions. Preventive functions have very high externalities which do not lend themselves to be managed by the contracting in process.  All these issues of hospital care and health services being synchronized is irrelevant as the integrated care provider would be taking care of hospital care anyway. Let the public health system focus on preventive and promotive work.

This public health cadre in contrast to the TN cadre is excluded from regulation. Regulation is a separate pyramid and separate players. Because they are also in charge of implementation and some level of primary care service delivery, it would be a conflict of interests if they also do regulation.

Problematic- 4 and 5

1.      Problem Statement 4: The NRHM goal was for all sub-centers, PHCs and CHCs and DHs to achieve a set of service guarantees. The actual achievements are far below this. Firstly in practice only RCH service guarantees were attempted. Secondly even on RCH, only one in 3 PHCs reached 24*7 level functioning. Though almost all CHCs reached the level where PHCs were supposed to reach, very few reached the levels of an FRU which they were supposed to reach. And third even in RCH, the actual skill level and range of services provided are less.

Problem Statement 5: Almost no facilities achieved IPHS. The rate of improvement of facilities to reach IPHS is very poor.. Almost one in 5 CHCs reached the level where CHCs were supposed to reach in terms of service provision.

These root cause analysis of these two problems are inter-linked and complex. Firstly the goal of IPHS was interpreted to mean a general effort to simultaneously and in parallel improve all facilities by providing the same amount of inputs to all and expect the same amount of service delivery by all. There was no sense of prioritization, and no factoring in  peoples preferences, and no strategy of doing so. With such a high pre-fixed output requirement , all community planning becomes redundant. Also since in practice inputs especially in HR and skills are limited, whereas ability to procure equipment and build infrastructure is unlimited- huge mismatches arise. Most important is peoples preferences- the rise of roadways and transport and communication means that it takes about the same degree of difficulty or ease to reach the district hospital or block hospital as it takes to reach the PHC or sub-center. And since services are more assured in the higher facility people opt for that facility. Also even amongst a number of facilities of the same level people have preferences- one sub-center attracting a huge clientiele whereas the neighbouring ones attracting none. Also, the density and quality of private providers makes a difference.  But there was space for none of these considerations in the programme design of NRHM. Efforts to introduce this in the later years met with serious resistance as a rolling back of commitments on one hand. But one could interpret this resistance also as a way of ensuring a programme design where no-one can perform and since everyone would fail to reach targets, no one would be accountable. The entire civil society mechanisms (and planning commission) worked overtime to re-inforce this by carefully detailing and highlighting the sub-centers and PHCs etc which had not reached the goals- without examining contexts, or the figures of which had reached them.

On the RCH focus there are many contributory factors. Firstly and undeniably the revival of the public health system was driven by JSY and this meant institutional delivery focus- not even RCH. Secondly, the RCH-II was the pre-eminent consideration of the NRHM- and in one framework of understanding NRHM was an additionality to help the goals of RCH-II be achieved. Thirdly RCH-II brought along programme designs, monitoring structures and capacity building approaches with finances for RCH goals. There was no such corresponding inputs for trauma care, emergencies, NCDs or other Communicable Diseases. The little that was available, were introduced as separate vertical programmes outside the NRHM- because the NRHM was seriously beleaguered by multiple attacks and one did not want to invest more in what could have been a sinking ship. Also in directorate circles there was a deep suspicion that just as general administration had captured the RCH programmes, in the name of integration it would capture the disease control programmes also, leaving the latter redundant. 

The IPHS understanding of standards has limitations. Standards are defined only in terms of inputs- infrastructure, equipments, human resource numbers, supplies. They need to be defined in terms of services available- both for quantity and quality. One could thus achieve the inputs without the service guarantees. And more often one could achieve 70%of the inputs and use the non achievement of the other 30% of inputs to justify non achievement of 70% of service guarantees.

The incremental innovation therefore proposed is that the goal be defined as achieving standards of care for RCH services, for emergency and trauma care services, for infectious diseases and non communicable diseases- for a district as a whole- treating the district health society as the integrated care network.  The standards of care are defined in terms of time taken to reach these facilities and the package of services which would be available there. All services would be quality certified.  That in RCH care, every district should reach it in three years, and for emergency and trauma care in six years and for the rest in 10 years- or two plan periods. There is no insistence that every PHC and CHC should have the same package of services. There are however three levels of care and the standards are with reference to levels. Level 3 is what currently a specialist in that area provides. Level 2 is what a competent MBBS doctors supported by a team of other doctors and nurses could provide. And level 1 is what a paramedic team, with or without a doctor or mid level care provider could provide. Thus we could provide cataract surgery in only three sites in the district and the entire range of ophthalmic surgery in only the district hospital and check up for refractive errors and detection of cataract- primary care at 20 sites and so on.

Thus a district provides service guarantees and not each facility. But each facility has a list of assured services, which are publicly declared- and if a patient enters the portals of such a facility for such a service, then it is the responsibility of the district to either provide it there or transport him or her to wherever it can be provided. If it is not available in any public facility, but only in a private facility whether within or outside the district, then the district health system purchases that care from a private provider and fulfills the guarantee. There are district level rate contracts that enable such purchase.

The strengthened sub-center and the primary health center would hold a family health card of each family and individual and between them provide the preventive and promotive and primary level curative care as is needed for every family and refer to the next level where required.

For a certain case load of patients seen in each of these four categories of care- an operational cost is paid to the facility which includes provider incentives to the health team. If the facility is quality certified then the unit rate of reimbursement is higher. If the package of services in each of these four areas is more comprehensive- i.e has less exclusions then also the unit rate of reimbursement is larger. One does not have to calculate each single service provided to make the payment. We would use the concept of cost drivers- which means indexing the payment to one or  other services which would be indicative of the whole package. Thus the reimbursement is per institutional delivery- but we understand this to mean, that a certain number of safe abortion services, RTI, STI care, adolescent health services, antenatal and post natal complications are also managed- and the package is costed on this basis. There are techniques of doing this- and based on NHSRC work in this area, we think this would be much easier to construct than any other alternative option. Would become more difficult for non communicable diseases- but even this could be done with a larger set of cost drivers.

No innovation only improved administration:

This is complex and difficult to administer. The DHS would have to have a mechanism to monitor and pay accordingly. Trend would be to purchase services- already they refer profitable cases to private sector. Why can we not make every sub-center and PHC work. This will just cutback on sub-centers and PHCs, We can give more untied funds to those facilities providing more care- but not further. IPHS must stay. If we place the facilities under panchayats and put community monitoring in place, we can make every PHC accountable.

Managed Care Option:

This ordering of care provision is precisely what must be done – and this is what, precisely, is meant by the integrated care network. But one cannot see the government doing it. Any HMO can do it, much more efficiently… for it would not invest in under-utilised and unnecessary capacity. It would contract in only those providers public or private that it needs to provide this level of care.  The district hospital plus two or three contracted in hospitals would be the key and one works backwards to identify the number and type of pre-hospital care that is to be provided.

 We welcome placing NRHM strengthening all public facilities to achieve IPHS and community monitoring to see whether it is done- but that may be done in parallel and by a different route. This is justified as MOHFW should have the space the strengthen the public health facilities to play the provider role and also as they have also public health functions to perform. Overtime that would make it abundantly clear, which providers are able to provide quality care and which are not, because people would have a choice and the choice they make would be the final judgment.

Payment is by a single capitation fee for the entire district network.

Problematic- 6

1.      Problem statement 6: Quality of Care in public health care facilities is a problem.

It need not be. A quality policy for public health facilities would have the following components:

a.    Every public health facility should have a quality management system in place and be scored annually and given a quality score.

Those above 50% ( or 70% - whatever) are quality certified. Those above 90% are “ star” facilities.

The certification should be done by quality assessors registered with the QCI. The certification is for having a QMS in place- the score says where they have arrived with respect to a desired level of care.

It should be done against quality standards specified by the state health society- with technical support as required.  Quality standards differ from IPHS in that they are standards of care. Thus we say average patient waiting time not to exceed one hour. Or standard treatment protocols of care are followed. Or toilets are clean and usable. In-Patient Diet meets food safety standards and is balanced diet, as appropriate to the illness. Patient satisfaction with provider courtesy and behavior and overall care provision exceeds 70% in a standard questionnaire etc. Since there is an obsession with input standards, there could be a parallel scoring and rating done for “achieving IPHS.” There are some overlaps. Thus one could say at least one staff nurse on duty for ten occupied non emergency beds during the daytime etc.

There should be some incentivisation- at least an annual bonus for staff in quality achievement. Thus if the certification is lost in the next years inspection, then the bonus is lost. Another suggestion is to given a higher rate of operational cost reimbursement for a facility which is quality certified.

2.      One needs to understand the QMS approach to quality. Simply put a QMS has four steps –

·         1.  it maps the current processes- of how work is organized and arrives at a document which points out all the gaps between the standards and the current situation along with a cause analysis.

 2.Then it defines how the work must be re-organised, capturing this in a document- and making some person in charge of ensuring that this process is reorganized according to what is written in the document. It also trains each process owner and participant to understand the re-engineered process as written in the document.

3. It then calls for each person to maintain a record of their activities in line with the document- which is a record of whether they have followed the processes as specified.

4. Finally at internal audit and external audit, the management looks to see where there is a conformity with the process as laid down and takes corrective action in case of non-conformity. Sometimes it may require re-thinking the process flow itself. It may also needs inputs- but the strength of this approach that for every level of inputs there is a maximization of quality outputs.

Quality is thus de-mystified. This system has been achieved in 74 hospitals and over 600 facilities are in this process.

3.      Many facilities would need the support of an external  technical support agency to put a QMS in place. This has costs, mostly in human resources. The costs depends on what is the details we get to. For example we may make checking for calibration of all equipment and tests as mandatory- or we may choose to not do it- but then what is meant by quality?  The external costs of management support for a QMS could be in the range of Rs 10 lakhs per year for a 100 bed district hospital. If the QMS management support is provided by an internal team, the costs could be considerably reduced- but it still would have costs- say Rs 3 lakhs per year. And more important there is a lot of human effort. One could have hospital managers and facility supervisors trained in this- in which case the costs becomes even less. The point is that it is universally possible and it would have costs that come down with scale and commitment.

NABH is not an alternative. The standards have high input costs, and many in essential requirements, and systems of verification are not transparent.  Even after crores of expenditure public facilities fail to make the grade, whereas for much less private facilities get accredited. There is a conflict of interests for QCI takes the contract for both certification and for the management support- whereas by rules these should be separated. Governance of QCI needs a MCI like makeover.

Quality assurance committees (QAC) are useful and help facilities to improve and get certified. But without external certification, public recognition is difficult, and it would be vulnerable to hostile action. Also it makes for much greater patient safety comfort and satisfaction where a QMS is in place- and a QAC approach without a QMS is inadequate.

The No Innovation only Improved Administration position:

This is fanciful and costly. The facilities which are quality certified do not look any better off. There are still gaps. What we need is just stricter administration and community monitoring. Form a quality assurance committee and ask them to make an inspection using a check-list. The facility officer in charge has to be asked to then close the gaps. Make a repeat visit after three to six months and if the gaps are still there, take action against the officer. This was what was tried during NRHM. It did not work, because it was not tried seriously enough and not persisted with. Another view is that if we add civil society members in the quality assurance committee and make it accountable to community it would work.

If one must get quality certified then go for NABH, where though one spends more the quality of care is “visible.”

( there is also a sub-text- that govt care is for those who cannot afford private care- so the importance in quality is only to get some RCH goals like maternal and infant mortality decreased. A general QMS is a luxury).

The Managed Care Position:

One cannot force the public facility to provide quality. The trick is in allowing public choice. Let them choose between a limited number of facilities as to which to go for. With the assurance that it would be cashless service even if it is their designated private provider. There is a risk that the private provider will not provide quality of care in such parameters as are not visible- eg following standard treatment protocols, or calibration of equipment etc. For which reason one has an independent authority which will examine and specify the quality standards.

However both the standard setting authority and the examining authority should be independent of the government. Quality is quality- and there is no quality for govt and quality for private. And as government is a provider of services, it shall not also set the standards.  NABH is a good first step.

Of course this would mean that many small providers and public facilities may not get quality certified, but they can be supported through NRHM to achieve the quality standards- not be allowed to function by lowering the standards. Corporatisation is not a bad thing unless one is ideologically prejudiced. It allows greater investment and management support.

Problematic – 7.

1.      Problem statement : It is difficult to find doctors and nurses to work in rural and remote areas.

The causes for this lie in the economic loss that doctors face when they go to work in rural and remote areas and in the professional and social isolation.  It costs more to travel to the place of posting, to stay there also has costs, and one needs to come out often for visiting family more often. Often a second home has to be established for family, children sent to boarding school etc. There are no avenues for private practice. Professionally one needs a team to work better and keep up skills. Also one has less variety of cases to manage and less opportunities to learn and upgrade skills. There is also less technology available, which per se is professionally demotivating. Socially there is a cultural gap between the provider and the local public. Families find it even more isolating and difficult to adjust. There are also tensions between provider and users as what is provided does not quite reach upto what is expected.

From both national and international experience we know exactly what is to be done to overcome this problem. Its not a one time magic wand, but it is a direction in which we must sustain – not like treating malaria – but like treating diabetes- could have a normal life expectancy provided one persists. Its incremental innovation.

To address economic loss we need a bundle of monetary and non monetary incentives. ( hardship allowance, boarding fees for children, retaining family accommodation at headquarters, leave travel and more leave etc). To address professional isolation we need an active telemedicine back-up, a peer support network and a positive practice environment and preferential access to skill upgradation and training programmes. We also need to create a cadre who by training and orientation see themselves as working at this level of technology. To address social isolation we need to preferentially select candidates from the local community for entry in professional and technical education, and create mid level providers who are conditionally licensed and oriented to work in such settings. Posting husband and wife together in such an area also helps. We also need positive measures of social interaction between provider and the community he or she serves so as to close the gaps. It is important to note that getting some person somehow to work for sometime in the difficult area- is no solution. We need the right person for the right place.

We also know what does not work. Compulsory postings do not work- whether short term or long term. No harm, however,  in keeping it on the agenda however. It is unlikely that anyone would be happy to let this go. A one or two year posting may help because about 5 to 10% will see a calling- and go back there to settle there. That is not a small number. Even the others would appreciate the problems better- to the extent this works. 

No Innovation, only Improved Administration position.

It requires administrative and political will. Make rural postings compulsory. Also have compulsory posting by rotation. Everyone needs to do a three-year term. It is not possible to do a special allowance because then school teachers etc will ask for it. Nor have reservation for students from these areas- because merit would suffer. And so on.

Managed Care Position:

One needs “disruptive innovation”- such great innovation as only HMOs can provide. One approach is what 104 services tried- the doctor in the box. Another is what Pathfinders with Warren Buffet/Gates financing is trying. Devi Shetty has also a similar suggestion and so too does Gautam Sen’s HMO- (forget his organization name- runs on venture capital)tc etc. The Arvind eye care does this for eye care. In Tripura the tele-ophthalmology model does this – and so on.

Broadly the approach is to have a rudimentary care provider at the local level- a six month trained paramedic at the village level in one model, a ayush doctor in another, local MBBS persons contracted in a third. These first line providers would have telemedicine link with a call station, where using algorithms, higher qualified paramedics and a few doctors would provide back-up and care.  Those requiring primary referral would be pulled to the nearest accredited provider of their team and those requiring hospitalization to the nearest hospitals. The network is paid on a per capita basis. All the problems of lack of providers in remote areas is thus history- poof- it vanishes. But incremental innovation will not do. What one needs is called “disruptive” innovation. ( NB- in this semantics disruptive innovation is not a bad word- it is a higher and more worthy form of innovation as compared to mere incremental innovation).

Problematic – 8

1.      Problem statement : Human Resources- 2: Most of those who are posted absent themselves. Workforce motivation, work performance and attitudes are poor. Basic workforce management is appalling. Promotions, transfers, postings, irrational deployment of staff and so on are terrible. Whatever other innovation we do, will come to grief on this bedrock of poor workforce management.

Incremental innovation would of course require the creation of a HR management cell, equipped with a HR management applications and with it some transparency on postings, work outputs, transfers etc. We don’t need anything sophisticated. Just click on a facility in a web-site page- and see who is posted there and the outputs of that facility as a whole- never of individual team members. When transfers happen they happen in the counseling mode (TN, Karnataka have this in place)- completely transparent. Financing of NRHM can insist on this.

Other than this we need to put more effort into the creation of a positive practice environment as suggested earlier- along with provider incentives for those who have unusually heavy workloads. These will not solve the problem, but it could diminish it. Quick firing etc- are neither needed nor useful and labour laws are not the problem. Recruitment can however be streamlined- Haryana style with the state service commission only acting as the regulariser.

There is also a case for regular appointment into district level cadre with copayments by tribal development agencies etc so that cadre in difficult districts get higher payments. 

Other than this the accountability mechanisms detaled later will help.

No innovation- improved administration.

This is an area we cannot insist except for rational deployment of staff. We need to leave it to the states. However we could make posting of gynecologists, pediatricians and anesthetists, especially those trained by NRHM at the correct place as a mandatory condition. As NRHM has paid for this we have a right to demand this. States have also to insist that ANMs stay at their place of work and doctors and nurses work for 8 hours etc.

Managed care position.

We told you so.  This is all easier said then done. Not unless public providers have to bid to be included and people have a choice to choose or reject the public health system, can this be addressed.

Problematic- 9

1.      Problem statement : There is a need to ban private practice by government doctors. But this has been a very intractable problem.

Incremental Innovation: Where it is already banned and the ban is working immediately extend support and reinforce the process.  Perhaps a study and skill upgradation and sabbatical fund for such states would help. Eg Himachal. Where it is banned and not working well- help strengthen the working of the ban. Help build up professional satisfaction, take action if errants are few, quick replacement of those who leave when the ban is enforced and use civil society to isolate the most high profile doctors who break the ban. But again packaged as a central incentive for good workforce practice. Where it is officially allowed- introduce differential ban- banning in the main cities and medical colleges- where there is lucrative private practice but also high case loads in public facilities and allowing it for the other areas. This is because one is afraid that many would leave. Also a strict enforcement of those who do private practice on public time. Also the introduction of kick back –conflict of interest statutes. No referral to a place where you have a kick back or share or a family member is working. Seek support in IMA, IMC, civil society for this. Requires a lot of skilled government action.

No innovation- improved administration:

It needs to be banned- but states have to take a decision.

Managed Care Option:

This is inevitable and even desirable. Acknowledge it and deal with it.  The HLEG proposal is that a contracted in party can be allowed 50% in patient care and 75% outpatient care. We can extend this to doctors working in the public hospital also- but they have to bid to be a part of the district care network. 

Problematic -10

1.      Problem statement – 1. A large part of the funds given to public health systems are returned unspent. How can we improve public health expenditure if we have to go only with public facility provisioning.

2.      This a bit of chicken and egg situation. Whenever there is an increased investment there is a lag before absorption capacity picks up. Absorption was more of a a problem in the early years of the NRHM. In the last  two to three years this has picked up. Looking at the pattern across the states there are  six features that correlate with better absorption- listed not in the order of importance- but in order of ease of implementation.

a.    Better financial management – Adequate staff and systems for financial management

More decentralization- powers to spend within an approved budget without having to refer to district/state for sanction of each line item.

Separation of  revenue expenditure from capital expenditure – with a fund for the latter and separate releases for each against utilization on each. Other wise slow capital expenditure slows down the revenue.

b.     Differential financing  –allocating funds to facilities and districts according to requirements and rate of expenditures reflecting the volume and range of services provided and not based on a normative allocation.

c.       Stronger management structure – Increased institutional capacities for management leads to improved expenditure. Multiple insititutional arrangements at state and even district with capcity to spend against approved annual budget and achieve the targets is a must.

d.      Human resource deployment –Almost 50% of the funds absorbed would be directly on salaries  and  indirectly even  absorption of funds in supplies and equipment would depend on adequacy of human resource deployment. With under-staffing both get affected. An alternative to creating posts is contracting in or contracting out services- which is just another form of increasing the human resources deployed. The experience was that except in some very limited areas, ( eg. emergency response and patient transport systems) these routes of increasing human resource deployment and therefore expenditure were equally if not more difficult to achieve.

No Innovation, improved administration option:

Better financial management is acceptable. The next four are considered either difficult or problematic to implement.  The last – on human resource deployment, requires a large state govt. commitment which one is not sure about.

Managed Care Option:

Part of the funds that goes to strengthening public health provisioning role  and for public health functions- about 1% of the GDP, about the amount currently given to NRHM, may continued to be given to NRHM and MOHFW. This is the inherent capacity of the public health system to absorb funds. And given efficiency of use, no need to invest more in this route.

The rest of the funds could be given to states through a parallel route- as additional central assistance or whatever. Since this would be used for paying capitation fee to the providers, the entire amount would be spent on day 1 itself. Each year as more districts are added on, more funds would be spent. Absorption would not be a problem. In case the pilots are not successful and PHFI takes too long to do this, we could use it to pay premiums of Arogyasri like project and RSBY like programmes. Of course these are not optimal, but in the interests of increasing absorption, we have no option. Paying premiums are also sure-shot ways of increasing absorption of funds. This increased investment in such a route would immediately be reflected in both economic growth contributed to by the healthcare industry and even be visible at the stock exchange.

Problematic 11:

1.      Problem statement: Accountability has been very weak and difficult to ensure. This is despite the accountability systems in place. In particular the district health society and state health society system does not seem to be ensuring this. Giving more money to these guys is asking for trouble. Just you see Uttar Pradesh!!

There are many incremental improvements that are required. These could be listed as:

a.    Separation of powers of governing boards from executive committees of  state health society and the district health society and RKS. Chairpersons of the board to be held accountable for holding the meetings and review of the programmes and chairpersons of the executive committee for implementation and outcomes.

System of periodic concurrent audit, and an annual audit for all districts to be strengthened- with black listing of district officers who have adverse comments from holding district management posts.

External surveys by AHS/DLHS have to be consistent with HMIS reports. Over-reporting on key parameters - should hold the HMIS officers accountable- not service providers

Community monitoring of facilities facilitated by non government organization should be strengthened with powers of central govt to appoint in consultation with states through the AGCA mechanisms and finance them through the same.

2.      In addition to the above, most of which is in place we need to add through financing incentives that fair, rule based and transparent mechanisms  are put in place for the following( in order of urgency)

a. Appointment of the main Chief Medical Officer of the district by due process-  even by DPC would be adequate. But no untied fund to any district which does not have a duly appointed CHMO.

b. Procurement and Logistics- system benchmarked in processes to the TNMSC

c. Postings and Promotions- as discussed earlier- in a web-based system as being built up in Karnataka and already implemented in TN

d. Contracting-in   protocols for different forms of public private partnership on NRHM funds should be vetted by a professionally competent technical advisory body at the national level- and a written opinion taken. State has discretion to act on it – but since many of these contracts go to court, state would be well advised to heed it if it is reasonable.

e. Use of infrastructure development funds- separate capital account, benchmarked to key processes, with a management cell in charge.

No innovation, only Improved Administration Position.

If we put too many conditions the funds just will not get spent. We can try some of these if the states agree. But health is a state subject and we need to take the states on board.

Managed Care position:

We could additionally place NRHM funds and facilities under the panchayats and also have a strong community monitoring system in place.

For the funds that go to the UHC- that is a parallel stream and every insurance company and HMO is paid precisely because they have fraud busting mechanisms like TPAs in place. The combination of market forces expressed as peoples choice would make regulation unnecessary as is the principle in which RSBY is organized. In addition a national accreditation board is there and under this an external system of evaluation- which should be adequate.

Problematic : 12:

1.                  Problem statement: Despite commitment, there are no emergency medical response systems in place.

Today there is an emergency rescue system and patient transport system in place. This needs to be linked up with emergency medical care providers. In most states the existing model ensures emergency care even by private facilities for 24 hours. The question really is whether we go with the Dial 108 model, or whether we change it.

We need to note that in many ways this Dial 108 model , is  managed care model, built on the very principles of managed care quite consciously. It was initially started as a model by Shri Ramalinga raju, to build a self supporting business model, with a monopoly on ambulance service provision- but changed to a publicly financed model out of compulsions  internal to the model and to a more full fledged managed care model due to compulsions external to the model (the collapse of Satyam, the court cases, the evaluation study, the change in nature of financing etc).  In this model, the state contracts in a service provider who contracts in hospitals as care providers but himself runs the ambulance service. The state currently tenders and gets the lowest price amongst competing vendors and this has brought the costs down- though there is now a limited number of vendors in the market. Near monopoly but not absolute monopoly which is very desirable in managed care models. The patient is allowed a choice of which provider to go to from the limited list of accredited providers with whom there is an MOU in the locality. Interesting to note that most patients prefer to go to public providers- 80 to 20 ratio- but this may change if UHC comes into place.

Incremental innovation would be aimed at strengthening a limited amount of competition and allowing multiple vendors to stay in place. This could be done by dividing states up into two or three contracts. Also to prevent any conflict of interests between ambulance service and hospital care providers. Also there is a need to separate patient transport and interfacility transport, leverage government owned vehciles better and in difficult areas gain efficiencies by local tie-ups. Standards setting and monitoring arrangements could improve. But basic message this works- and do not let it go. It is supplemental and not substituting to public health systems and for that reason it is likely to take hostile attacks against which it needs defense. ( civil society is the usual shoulders from which the guns are fired).

If all these are agreed to then center can underwrite upto 50% of running costs.

No Innovation, improved administration position.

·         Minimum interference by the center. Let states have it their way. Also its their money. Central govt has not got any financial commitment beyond the fourth year- and that should stay. Current central financing is a success story and let us not tamper with it.

Managed Care position:

·         As such it should agree with the incremental innovation position. There is however likelihood that a managed care system would consider ambulance services as covered under the single capitation fee and seek that the same HMO control this service too. Monopoly is always a desirable. There would be contestation between two monopolies and a chance of cartelization etc etc. Also it would migrate to parallel UHC funds.

Problematic 13:

1.      Problem statement: Clearly some form of CHW is considered as required, but there is no agreement on what is required.  The ASHA is getting well accepted both by communities and despite many difficulties she continues with enthusiasm. This is the problem. There are  growing demands for regularization and salary, but there is difficulty/reluctance  in visualizing a more or less regular community level care provision role – both in terms of organizing skills and outputs, but most important building a HR strategy for her.

Incremental Innovation would call for building understanding on the necessary complementarity of the three roles- as a community level care provision- because it is most costs effective and most feasible and appropriate to provide some types of care in the family and community context; as a facilitator to access services- because there are many types of care that cannot be provided at the community level and active support is needed for the poor to access health care services and as an activist because this is tied up with the rights of marginalized sections and one has to reach out to them and proactively secure entitlements to them. This would be a continuing role and even where RCH is no longer the urgency, areas like geriatric care, tobacco control etc would require a community level care provider. It follows that not only has one to build systems of training and monitoring- but one has also to build in systems for innovation of future programmes and roles related to the community level support function. Payments which are performance based but include both regular functions bringing in an assured monthly some and others which are variable would provide stability. And if the work definition and outcomes are clear, regularization is not something to be frightened off. 

Most of the problems of the programme arise from entrenched resistance to the idea of a community health worker- due to alternative requirements or programme theories of what an ASHA should be. These we examine below.

·         No innovation, only improved administration position:

Focus on getting the payments going, getting her to push for clear public health priorities- immunization, institutional delivery, more contraceptives usage, and some importance on newborn and sick child care ( most reluctantly- but seeing the point). Get the current training over- and slowly bring her into a commission payment mode with focus on social marketing- sale of sanitary napkins and contraceptives. It should have collapsed by now- perhaps it still can collapse. But at senior levels, the complementarity of the three roles is granted.

·         Managed care vision:

Not very relevant to the vision. (HLEG in its second chapter asks for two ASHAs instead of one, but its section on community norms, financing, UHC etc do not relate to ASHA at all. Of course we add, that we are not equating HLEG with managed care- though there are overlaps). ASHA is a good adjunct in social marketing, insurance recruitment, and go-between to bring cases to the integrated care network including private providers. The RCH-II design has been clear on this- stating both her non-clinical character and the voucher based linkage with private providers. But this did not happen, because NRHM spun her into a different definition.  One other possibility was that if she had six months training and could be the peripheral RMP fuelling in cases to the hospital care network-  but ASHA by design has too low an education level, and too activist a character to play the role of an obedient demand side management function. 

Problematic : 14

1.      Problem Statement : Village health and sanitation committees are very varied and performance and outcomes.

There are huge problems and multiple programme theories about what VHSNCs are and how they would work. The methods to study them are also weak.

Incremental innovation suggested is to focus on measuring situation on social determinants and acting on it- and basing a village plan around this concept. Much active conceptual and knowledge management work is needed before this takes off.

·         No Innovation, only  improved administration.

Just focus on getting the UCs in time. There is no harm done, and no great benefit to be gained. To the extent it engages the village in health programme it is useful Use it mainly for the VHND and another facilitator of services. But social determinants function is also welcome.

·         Managed Care option:

Not relevant to the discourse. Can be anything- even village health councils if you like the idea. But not too happy with NGOs doing this. Why not the panchayats.

Problematic 15:

1.      Problem statement - Health Information Systems provide poor quality data. Each vertical programme has its own health information system, and each department has theirs and they do not share between them.

Incremental innovation: allow every programme and every states to have its own system, even positively encourage them to have it. Only insist that it should share its data electronically with a central warehouse in the format specified. The central data warehouse should allow data from any system in its back end. In its front end it should allow any user to access whatever raw data has been shared with it. The central data warehouse and the standards to meet its needs are a central govt function, leaving it to the states.

The state systems should design systems that allow those entering data to be able to analyse their data at the point of entry and allow mid-level managers to access and analyse data of all facilities below them. Lower levels will have far higher data requirement then higher levels.

Most data quality issues are systemic information flow problems- not due to insincere or false entry- and these problems need to be attended to. Falsifications usually occur at higher levels, and systems must be proof to tamperings from above. If any level wants to correct or edit data, there should be an audit trail- someone asks the permission, some one gives it and what figure was changed to what on what date, why and by whom is to be recorded.

HMIS should be judged by concordance of internal data with external surveys. Training for use of available data is a priority. Even now the data is eminently usable- but the skills needed are not in place.

The other role of the center is to set the standards and the financing and procurement rules by which there could be a rapid development of e-health- at the pace at which it is possible given the capacity in each context.

No Innovation, only improved administration

We already have a web-portal. All we need to do is to ask everyone to enter in that same portal directly and to stop all other systems- all else is duplication.

Managed Care System:

We need a system where there is a electronic health record for every individual and every health encounter is recorded in this. This record is visible and portable inside the integrated care network and to administrators. It can be used by administrators to make payments, used to check compliance to standard treatment protocols and to monitor performance of each providers. It can be used by care providers to ensure follow up and enable referrals. It can be used for patients to know what care is provided.

The problems with the current HMIS are because they allow only aggregate numbers and one cannot see the names and the records.

Problematic 16

1.      Problem Statement: The principle of integration of all vertical programmes is well known. However integration of the vertical programmes has eluded us. The NRHM failed to achieve this.

We need a theoretical framework for understanding integration. Does integration mean to bring all the functions under an unified command structure- everything under the mission director perhaps? Or does it mean only to avoid redundancies and share in human resources, infrastructure – like having a common Xerox machine and laboratory technician for the RCH and the TB programmes. What are the advantages of integration and what are problems and why do we seek integration?

Tentatively we can state the facility –  PHC, CHC, DH are integrated units under a unified facility level command structure- and they deliver a package of services as they best can.  The point is they may need to be financed from different programme heads, have skills developed by different people, submit monitoring reports to separate people, and be supervised by different staff with different supervisory skills. These different financing and monitoring heads are created because at state and national levels certain programmes are being prioritized. The skills and supervision are under different heads because there is specialization needed at least at the higher levels.

So integration should be considered achieved if there is a) common facility and district plan, b) a common financing pipeline at the point of entry into district or facility, c) a sharing of information between the systems- and d)as much sharing of human and technical resources as is needed for optimization of use of the same. Otherwise, it is better to allow dedicated parallel and even vertical structures to ensure programme efficiency. Thus it is unlikely that integrating RNTCP data flow will give any advantage to the system, or even for vector borne disease or IDSP, but there certainly needs to be seamless sharing of information across the systems that does not happen today.

·         No innovation, improved administration option:

Unified command structure- with everyone reporting to one head is always better . Also one information system where everyone reports in. Multiple information systems with sharing will not happen. The opposite view would be to allow the status quo- and see unified structure as aplot to take away even more powers from the directorate.

·         Managed care option:

This is really not relevant. The HMO- or integrated care network- ensures integration and rational deployment or resources between the programmes. Those programmes that do not fall within the package of care, are of course to be left to NRHM to manage it in its own efficient or inefficient ways.

Problematic 17:

1.      Problem Statement: The principle of action on social determinants is well known, but actual forward movement on this has been limited.  There has to be clarity about what action is being required and of whom.

There are two areas of action- one relates to access to food and nutrition, safe drinking water and sanitation, education, poverty reduction and so on- all basically the work of other departments. Here the important step is to be able to set indicators at the district and GP level that can measure performance in these areas and by monitoring these find out which department or public service is under-performing. The coordination can be done at district block and GP level, and to the extent that the electronic monitoring systems of those programmes talk to the HMIS, and to the extent that the members of governing boards of these societies talk to each other on these indicators and their performance there could be better coordination.

The other relates to issues of caste, class, gender, other forms of marginalization, affecting access to care or even leading to forms of exclusion. Here the suggestion is that the VHSNCs have to be developed and equipped to play an active role, with ASHA as one of our key means of influencing them positively. NGOs support is also critical and in this work, more than in any other they should be roped in.

Though collecting data disaggregated by these break-ups is a requirement, the way of doing it must b thought through and carefully field tested. The intuitive way of approaching this problem is a prescription for HMIS disaster- but there are interesting and effective counter-intuitive approaches to this problem.

·         No Innovation, better administration approach:

We have formed the committees and structures. Officers have to be sensitized to address these issues. But let health dept do what it has to do well- let it not get overburdened with the work of other departments.

·         Managed Care approach:

This is an areas with high externalities. Hence the govt. through its public health cadre should focus on this, leaving the medical care to the HMO.

Problematic 18:

1.      Problem Statement: There is a requirement for technology innovation in a wide number of areas, since available technologies- drugs, diagnostics, devices. are not adequate or appropriate for the purpose. But how does one solve this.

Incremental Innovation approaches: There is a detailed report of the sector innovation council for the health sector that details this. May refer to that document.

·         No Innovation, only improved administration>

No new technologies are required. Improving health care is not rocket science. Just increased access to existing technologies through better administration will solve the problem.

·         Managed care option:

This is the real big strength of the managed care option. HMOs will be constantly innovating and improving on systems to gain efficiencies and maximize gains- in a way there will never be motivation to do within a govt system. HMOs would welcome innovations, promote innovations and even invest in innovations. In fact higher profit margins should be allowed so that HMOs can invest in innovation.

Problematic 19:

1.      Problem Statement: There is a huge problem on choice of technology and technology uptake in public health systems. One example is vaccine choice. Another is inclusion of a drug or device in a standard protocol, like the inclusion of co-trim in CHW protocol or iron sucrose in treatment of anemia in pregnancy. Unfair criticism could disrupt programmes, on the other hand there is a need to prevent corporate pressures. Policy paralysis in the face of constant controversy is also a problem. How does one overcome this.

Technology choice is one of the most difficult terrains of contestation, and one of the most impregnated with hidden power relationships. Also if one is not intervening at the time of innovation and design, then the system is a sense presented with a fait accompli- and a take it or leave it message. Though pushing unnecessary drugs or vaccines into the programme is a problem, preventing uptake of new or appropriate technologies and crippling public health systems is a bigger problem.

The incremental innovation proposed is of NICE- UK. Here the expert committee is chosen in a transparent manner, it has multi-stakeholder representation. Evidence is written up professionally and placed before the committee and publicly and counter statements are accepted. Then each contention and counter contention has to be replied to, and documented and then based on this written documentation, the committee passes its recommendation. Its not binding, but over time it has done so well in contestations in court and outside it, that people just go by it. Drugs that think they cannot stand this, prefer not to come to NHS- UK at all rather than face a rejection from NICE- even though such a rejection does not mean hospitals cannot use it. There are limitations to this approach- which can be discussed- but there is a need to create such an institutional format for decision making – as regards uptake into public health systems. One need not even wait for starting this up- one can start using the process.

·         No Innovation, only better administration:

We already have technical resource groups which are made by the govt, and which give its opinion. This would suffice.

·         Managed Care Options:

Yes such a system is needed. But there is an insistence that it should be sealed from govt influence- rather than that it should be sealed from corporate influence and certainly not placed with any agency which has corporate interests in it.  In fact the latter is much more important. NICE is a para-statal- autonomous in function, but fully financed and owned by govt.

Problematic 20:

1.      Problem Statement:  The private sector has 80% of the doctors, and 30% of the nurses and provides 80% of outpatient care and 40% of inpatient care. But there has been no serious effort to engage with it or harness its potential. Why this failure – though it was very much part of the NRHM. And what can be done to harness it.

There are many ways in which NRHM did work with private sector- and these are listed in the NRHM under the XI plan booklet. The point if true however that it did not go to scale.  One must remember that the private sector in India is neither very transparent, nor efficient nor does it submit itself to regulation. Even the income tax department can hardly get at them- leave alone our imperfect mechanisms. The Chiranjeevi approach did not replicate well in other states- but whether this is its true potential to replicate, or whether a better effort should be made is open question. Quality of care and standards in Chiranjeevi have been subject to question. RSBY and Arogyasri also have been queried on different grounds. Undoubtedly it is the EMRI-ZHL systems, that did best and after that a wide number of other patient transport systems and many forms of partnership that were supplemental to public health systems – including outsourcing of diagnostics etc.

The 8 principles that define an effective and sustainable  PPP could be spelt out as follows:

a.    Where considerations of equity are kept in mind and the care is accessible to the poor- usually through it being cashless.

Where the PPP is supplementary to the public health system and not a substitute to it.

Where the governance of the public system itself has basic degree or integrity and the contract mechanisms are fair and transparent.

Where there is no transfer of investment into private hands- and the private partner shares in investment and risk.

Where there is good cost and quality monitoring- independent of the data supplied by the partner agency.

Where the mechanisms of payment are made quick and with dignity to the provider.

Where there is no so –called efficiency in the arrangement only due to bad labour conditions or iniquitous payments to workers.

2.      Within these terms and conditions the potential for PPPs exists in the following forms:

a.    Some ancillary or component of services provided by  a public hospital- eg ambulance services, diagnostics, laundry, diet, counseling etc

Purchase of those specific secondary or tertiary care services which are part of the assured services for that level of care and should be available in the district/facility- but is not available for whatever reason. For example a district hospital is unable to provide C-section services may refer the patient to a nearby non governmental institution and undertake to pay for those services on a previously fixed rate. The government institution thus acts as a gate-keeper and monitoring processes can make this transaction and the private sector engagement is clearly supplemental to public sector. This purchase would be from the nearest point where it is available even if it is outside the district and the cost of transport would be included- provided that this service was one of the services on the assured services list.

Purchase of those services which are needed in great numbers but where the public provider capacity is exceeded. For example cataract surgery, or sterlisation services in a district. It could also apply where a secondary service load exceeds the quantity ceiling required for quality care. Thus a only gynecologist in a district hospital having to do say more than 5 C-sections in a day could be allowed to refer, if there is no one else available.

Contracting out of facilities which requires specialists or medical doctors if none are available, and an agency or even individual is in a position to bring them in.

Contracting in of a private care facility in a context where there is no public facility, but a private facility is willing to play this role. This could be applicable in urban agglomerations with large low-income populations seeking publicly financed care.

Contracting out those tasks where internal capacity is exceeded or needs to prioritized elsewhere- like contracting training of VHSNCs members or even ASHAs to NGOs.

Accrediting private facilities for demand side financing whether through insurance or through JSY like schemes.

·         No Innovation, only improved administration:

One could go along with most of the above suggestions, but in practice there would be lot of abuse and mis-governance. So let us not encourage it.

·         Managed Care system:

1.      People would have  a choice to register with either the public or the private provider for a specified package of care.  Obviously only where both are available is there a choice. Where it is not available, families would be catered to by the public sector.

Systems of supplementation like outsourcing the CT scan facilities of medical college and district hospitals should not be allowed. The choice is to be between only public provider system or an integrated care network system  that offers a choice between public and provider mix. The public health system would have to be retained for provision of a lot of care that falls outside the package- one cannot after all provide too much with an integrated care package costed at Rs 1500 per person when RSBY premium alone is gone above Rs 1000 and that is only about 25% of health care costs. Once the public health system develops an area, then private providers arrive and competition can be set up.

Part III.

What next?

If we accept the commitment of the state to publicly finance the major portion of health care and further we agree that public health systems have a central role to play in this, we are faced with the problem of public health systems as constrained to achieve this due to poor investment, poor governance/ administration and due to institutional barriers. The question is – what are these institutional barriers and how best do we overcome this.

One can see that from the discussion of 20 specific problematics, that the nature of research questions we would ask, the nature of alliances we would form and the nature of call for action that would emerge would all vary on whether we go with what we have crudely categorized into the three categories- the no innovation option, the incremental innovation and the disruptive innovation options. Or improved administration, improving institutional arrangements, or managed competition/care option.

It can also be seen that each of these three options are not completely compartmentalized and they admit of considerable overlaps- and unexpected alliances on specific issues from otherwise contrary positions. Depending on ones ideology, there would be a preference to stand within one of the three paradigms and incorporate learnings or action possibilities from other paradigms into ones own preferred solution. Or one could stand on ones own ideology and reject the other two paradigms.

One way forward is to describe each of these three ideological positions[4] as three programme theories- a reading of the relationship between context – mechanism and outcomes that a protagonist of one theory makes and then read the evidence through each of these three C-M-O lens. And see what happens. But that later….

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[1] There is a history of efforts to strengthen public health systems.  The most recent of these is related to the National Rural Health Mission.  In the nineties the dominant programme was the state health systems development programmes- especially the World Bank funded programmes- and its different variations leading to the Sector Investment Programme of the SIP- which shared a number of key features. These were defined by the Investing in Health, 1993, document of the World Bank. This went along with a number of vertical health programmes. In the eighties- the early part was the primary health care movement and the national health policy of 1983 which defined it. However by the late eighties this had become a much more selective primary health care approach. It is important to know and build on the lessons from these periods, recognizing that there are both useful learnings that have continued into the present and costly errors that we must not repe

[2] In the recent round of policy discussions in forums such as HLEG,  etc. formulations and experiences of NRHM or even the HSDPs, and the constraints they faced are not seriously looked at or learnt from. To address this shortcoming, this note may be read along with two notes circulated earlier- NRHM in the Eleventh Five Year Plan- A factual and conceptual baseline- and “ Proposed Revision of the Framework of Implementation”

[3] We note that all political or sectional interests need not accept this definition of a call to action.  It would be legitimate for representatives of different peoples sections, to demand better health care leaving it to government  to decide on how it should provide it. Again a number of policy thinkers both in civil society and academics may find the problems set out as too operational, at best calling for some minor operational research. The contention of this note is to formulate and examine alternatives at the operational level, because though larger principles of change can be agreed to by all, it may work itself out in very different ways with widely different consequences for outcomes, equity and democratic norms, when it comes  to the operational level.  In a separate note we shall relate this dialogue on operational issues to larger issues of institutional analysis and political theory.

[4] What could this three ideological positions be called- perhaps we could call the first statist, the second a political institutional analysis,  and the third a market oriented new institutional analysis. That would be confusing. To call it statist, democratic and market driven is simple- but it perhaps is wrong.