Nursing management on: Health sectors
The health sectors in many developing countries are undergoing major reforms at present, and a ‘sector-wide approach’ is being adopted to increase the impact of donor funds. In implementing health sector reform (HSR) and sector-wide approaches, both donor communities and ministries of health are interested in putting in place a manageable monitoring and evaluation system, against which the success of HSR can be judged. In the recognition of the weaknesses of health indicators to monitor HSR in the short-term, other indicators to reflect major aims of HSR are recommended: access, equity, quality, efficiency, and sustainability. In choosing performance measures to reflect these aims, a number of scientific (validity, relevance, reliability, quantifiable) and pragmatic (data available or easily collectable, data timely) criteria are proposed by which to judge the most appropriate performance indicators. Using these criteria, the strengths and weaknesses of performance indicators are discussed, as well as links between indicators and where they overlap. In particular, the conclusions about the success or failure of HSR depend not only on which performance indicators are chosen, but how they are defined and measured, whether current health management information systems can be relied on, and what alternative available data sources are available or can be set up. The next important steps are to: decide how many indicators should be on the final short list for monitoring health sector reform; rank indicators using scoring systems; assess data availability and quality; and decide on the final short-list of indicators.
Important achievements of health care in developing nations during the preceding years included the movement towards universal childhood immunization; expansion of oral rehydration therapy; and the approaching eradication of polio in the Americas. There was also increased recognition of new challenges in reproductive health, management of the sick child, and HIV/AIDS. Vertical and categorical programs had made a mark.
Nevertheless, it was also increasingly apparent that the health systems necessary to support and sustain these gains were seriously deficient and often deteriorating. As many sector reports and health sector assessments consistently demonstrated, health systems in numerous developing countries suffered from grossly inefficient and inequitable resource allocation, declining quality, and demoralized work forces. Patients were abandoning public systems, “voting with their feet,” by choosing private care, which was often of questionable quality. These deteriorating health systems raised questions of whether the significant health gains would be sustained when intensified donor-supported efforts ended, whether simply injecting more funds would be wise or effective, and whether new gains would be possible in the poorest countries.
“Health sector reform” promised a period of new thinking and innovation in health systems that would address this gap. Concepts such as “new public management” or “public-private partnerships” heralded an exciting potential synthesis of public purpose and entrepreneurial creativity that could launch a new period of rapid health gains. Innovations in health care financing and delivery were seen to be invigorating bureaucratically-run health care systems in more advanced nations.
Health sector in developing country (financing of health care)
Financing is the most critical of all determinants of a health system. The nature of financing defines the structure, the behavior of different stakeholders and quality of outcomes. It is closely and indivisibly linked to the provisioning of services and helps define the outer boundaries of the system’s capability to achieve its stated goals.
Health financing is by a number of sources: (i) the tax-based public sector that comprises local, State and Central Governments, in addition to numerous autonomous public sector bodies; (ii) the private sector including the not-for-profit sector, organizing and financing, directly or through insurance, the health care of their employees and target populations; (iii) households through out-of-pocket expenditures, including user fees paid in public facilities; (iv) other insurance-social and community-based; and (v) external financing (through grants and loans).
Health spending in India is estimated to be in the range of 4.5%-6%. These estimates are based on a weak methodological background. Therefore, an exercise was undertaken to construct estimates of health spending based on a National Health Account (NHA) framework. Such an approach enables a better and more reliable understanding of the size and structure of health financing in India.
Results from the NHA show that the estimated health expenditure in India for the year 2001-02 was approximately Rs 108,732 crore, accounting for 4.8% of the GDP at current market price. while health expenditure as a percentage of the GDP measured at factor cost works out to 5.2%.
Out of this, Central, State and local Governments together spend one-fourth of the total health expenditure. The share of other central ministries, which include railways, defence, posts and telegraphs, other civil ministries, etc. is estimated to be about 2.42% of total health spending in the country.
The estimate is based on direct spending by the ministries as well as reimbursements provided to its employees. Local governments’ resources for health are through transfers from State Governments and their own resources. An estimated 2.2
% of total health spending comes from the local government. The estimate involves only spending by municipalities and not Panchayati Raj institutions. It is to be noted that municipalities (in metros and particularly Mumbai Municipal Corporation) are major contributors among local governments while the share of Panchayati Raj institutions are a miniscule part of the health budget, since a substantial part of the panchayat’s are mostly composed of either Central or State transfers.
Public Financing of Health
Even though public sector spending accounts for less than a quarter of the total health spending in India, it has a major role in terms of planning, regulating and shaping the delivery of health services. Such public provisioning is considered essential to achieve equity and to address the large positive externalities associated with health. As a result, a vast and widespread public health system grew over time across the country; there were 137,311 sub centres, 22,842 PHCs, 3043 CHCs, 4048 hospitals and a workforce of 345,514 in 2001-02. The way in which the sector is financed determines the effectiveness of service delivery and requires an understanding of the financing mechanisms in this sector.
Health being a State subject, the sector is financed primarily by the State Governments. The per capita total health spending was estimated to be around US$23 during 1997- 2000 (World Bank 2003). As compared to the levels of spending by countries such as Sri Lanka (US$31) and Thailand (US$71), the spending in India is substantially low. A breakdown of health expenditure reveals that expenditure by the public sector in these countries is twice that of India. Substantially higher levels of health outcomes in these countries as compared to India clearly indicate that there is a strong case to markedly increase public sector spending on health, as stated in the National Health Policy 2002 and the National Common Minimum Programme (CMP) 2004.
The primary source of public financing is the general tax and non-tax revenues. These include grants and loans received from both internal and external agencies, which face competing demands from various ministries and departments.
This pool of resources is used to finance the Centre’s and States’ own programmes. The Central Government plays a catalytic role in aligning the States’ health programmes to meet certain national health goals through various policy guidelines as well as financing certain critical components of centrally sponsored programmes implemented by the State Governments. In addition to tax revenues, a meagre amount is also raised through user charges, fees and fines from the sector, and further supplemented through grants and loans received from external sources. In the case of local governments, the respective State Governments largely finance their health programmes. Local governments do raise resources through user charges and certain fees though the quantum varies widely from States to States. Overall, the sector is underfunded, not without consequences.
Health Expenditure by the Central Government
Major policy initiatives and reforms relating to health emanate from the Ministry of Health and Family Welfare (MOHFW), which plays a crucial role in financing this sector.
The Union Ministry of Health and Family Welfare consists of three departments. The department-wise break-up of the Health Ministry’s budget suggests that over one-third of the budget is spent by the Department of Health, while roughly two-thirds goes to the Department of Family Welfare. The Indian Systems of Medicine and Homeopathy (ISM&H) (AYUSH) Department receives a paltry 2%-3% of the total budget of the Ministry. There are 5 important aspects to the nature of central spending in recent years:
1. The gradual reduction in the proportion of funds released to States at a time when the States were themselves under fiscal stress;
2. The sharp reduction in capital investment in public hospitals at a time of technological innovation, shifts in the epidemiology and health needs and expectations of the people, besides the sheer increase in disease burden in absolute terms;
3. Increased subsidy for own employees;
4. Low priority to preventive and promotive health; and
5. Allocate inefficiencies under the National Health Programs
Health sector in developed country (financing of health care)
There is an elaborated inter-governmental system involving different levels of senior government officials for the discussion of policy issues in Canada. Since 1906, the Prime Minister of Canada and Premiers of the provinces have held formal meetings, usually once a year, to discuss inter-governmental affairs, including health. Health policies have also been the focus of discussion in the recent three First Ministers’ Meetings, which reaffirms the commitment to a publicly-funded health care system framed by the Canada Health Act.
Regarding the different roles of the federal and provincial governments in health care policies, the federal government’s roles include:
Þ offering federal transfer payments or funding assistance to the provincial governments for the provision of health care services consistent with the principles of the Canada Health Act;
Þ being responsible for the programmes and regulation in the area of health protection and promotion, health security and disease prevention;
Þ ensuring that drugs, vaccines and other therapeutic products sold in Canada are safe, of good quality and therapeutically effective;
Þ fostering medical and scientific research through funding and other means; and
Þ Ensuring access to health services by specific groups of Canadians, including aboriginal people, military personnel, the Royal Canadian Mounted Police and inmates of federal prisons.
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