Transcript Health (Policy &) Systems Research: What defines the field

Devaki Nambiar PhD, Kabir Sheikh MBBS MPH PhD
Health Governance Hub
Public Health Foundation of India
4th Technical Review Meeting for the HPHFKH
10th October 2011
A team of researchers across our
family of institutions in five cities
Core interest in the relationship
between health systems governance
and social justice
THEME AREAS
Regulation and stewardship
Community action for health
Health workforce governance
Pharmaceutical policy
Urban health governance
Public health philanthropy
As India moves towards Universal Health Coverage…
Sheikh, Saligram, Prasad (2010-2011)
Funding: Nossal Institute
Normative position:
Regulation as a means to health equity, health rights, development (Mackintosh 2007)
Approach:
Backward Mapping: ‘bottom up’ understanding of field level phenomena generate
policy needs (Elmore 1982)
Process:
Pilot study in two states
in India
Delhi
MP
Development of tool
for policy mapping and
gap analysis of policy
design (relative to
target) and
implementation
(relative to design)
Costs of care
for users
Quality of care
Conduct of
providers
Accessibility of
care
Regulatory targets
identified from indepth literature
review on LMIC
‘mixed’ health
systems
(Oxfam 2009,
Nishtar 2010)
Delhi
Madhya Pradesh (MP)
Cost of Care
RSBY and government subsidies to private
hospitals both aimed at reducing costs of
private care for EWS
Do not address the high incident costs in
public facilities, or financial protection of
non-EWS. No direct control of care costs, no
regulation of competition.
No known laws or regulatory policies for
the curtailment of costs for users of health
care, other than recently introduced Janani
Sahayogi Yojana (Mothers’ Assistance
Scheme)
Quality of
Care
No credible regulatory mechanism to limit
practice by unqualified providers.
Absence of credible community-based
forum for grievance redress.
Absence of credible community-based
forum for grievance redress.
Not addressed through act or policy
Variable workforce distribution, only
mandatory rural service, no incentive
based policies
Conduct of
Providers
Accessibility
of Care
Delhi
Madhya Pradesh (MP)
Cost of Care
Information asymmetries impede uptake of
social insurance scheme, also lack of
stringent regulatory component. Reduced
investment in regulatory capacity of
relevant departments impedes enforcement
of EWS free-bed condition for hospital
subsidy
Clinical Establishments Act, PNDT, MTP:
Implementation is partial due to personnel
constraints problems of inter-departmental
coordination, affects relationships with
hospital owners
Quality of
Care
Multiple contestations of NHRA have
diluted content. Partial implementation due
to personnel constraints and organizational
inertia, active resistance of medical
fraternity
Conduct of
Providers
Councils role less disciplinary, more
advocacy for professionals’ rights, medical
sanctity
Self-regulatory council’s commitment to
disciplinary functions, made problematic by
closeness to associations who oppose
regulation.
Engagement with additional tasks such as
reducing quackery greater than performance
of disciplinary roles.
Accessibility
of Care
Health authority subordinated to urban
development authority in determining
location of new hospitals
Implementation of rural medical bonds
hampered by extensive contestation by
doctors’ groups, problems in coordination
between government departments involved
in placements
Sheikh, Gilson, Bennett, others (2011)
Commissioned by PLoS Medicine
SYSTEMS FUNCTIONS
Systems defined on basis of their
utility, problems mainly relate to
efficiency
Decisions are concentrated, flow
in one direction
Policy content not problematized
E.g. WHO ‘building blocks’
Policy Decisions
Systems
Human Resources, Finance,
Medicines & technology,
Organizational structure,
Service infrastructure,
Information systems
Outputs
Outcomes
COMPLEX AND SOCIALLY
CONSTRUCTED
Decisions are diffused, relationships are
non-linear
‘Software’ critical to health systems
performance
Problems (and solutions) are related to
(understanding) complexity
Shaped by particular politics, culture,
discourse (and not others)
Solutions within and beyond health
systems
(e.g. Frenk 1994, de Savigny and Adam
2009, Lambert 2006, Illich 1970)
ARENA
International
Systems ‘Hardware’
Human Resources, Finance,
Medicines & technology,
Organizational structure,
Service infrastructure,
Information systems
Systems ‘Software’
Ideas and interests,
Relationships and power,
Values and norms
National
Subnational
Local
Thank you
[email protected]