The Vision2020 document of the Government of Andhra Pradesh sets out goals to achieve improved population health status and access to responsive basic health care services. Certain key priorities were identified by the Vision 2020 document including universal access to primary health care, strengthening process of institutional development, increase community participation, etc. The Health, Medical and Family Welfare (HM&FW) department initiated a series of ground work, and internal discussions. The Department For International Development of the Government of UK (DFID) and other International Agencies have been showing interest in the Vision 2020 process of Andhra Pradesh. Representatives of DFID - India office and other International agencies like the European Commission office in India and the World Bank were involved in some of these discussions. Health sector development and reform proposals prepared by executive agencies like the Director of Health, Commissioner Family Welfare, Commissioner APVVP, and the Director Medical Education were presented in some of these meetings. During the course of discussions on the proposals prepared by the Executive Agencies, the need for a more comprehensive brainstorming session was being felt. It was realised that all important issues should be carefully identified and many issues may require more in-depth study. Accordingly Government of AP commissioned¹ the Institute of Health Systems to assist in the strategy development process. This workshop was organised to bring together health sector officials conversant with local needs, operational difficulties and possible opportunities for improvement, health system researchers, health policy consultants, and representatives of International agencies interested in the health sector reform in the state. The workshop was meant to be a brainstorming session. Its objective was to start with the Vision 2020 goals and brainstorm about possible strategies towards achievement of those goals. We recognised that the process of developing strategies to bring about required overall health sector reform for achievement of Vision 2020 goals will require adequate understanding of the issues, gathering of evidence for policy, and concerted efforts to design various components of the reform process. A well thought out and adequately planned strategy is the minimum prerequisite for success of any reform process. The purpose of this workshop was to brainstorm and identify all relevant issues, potential leads for reform and agree on the modalities of continuing the strategy development process.

We invited participants from the government dealing with the health sector and financing, representatives of health system research institutions, non government organisations, and International agencies about whose interest we were aware of. We are very much pleased with the positive response from the invitees, most of whom were kind enough to take the required time out of their busy schedules and join the workshop. We are very grateful for the excellent participation and candid exchange of ideas. We present here the proceedings of the workshop and hope that these will further stimulate the health sector development and reform process and help realise the state's vision of improved population health status and universal access to health care.

Early preparations for the strategy development process has been funded by the Government of Andhra Pradesh. Funding for conduct of this workshop was made available by the DFID-India office. We thank both the organisations for the financial support. We would also like to record our appreciation and thanks to Shri C. Arjuna Rao, Special Chief Secretary to Government of AP HM&FW department. He has been closely following up the work on strategy development and has been a constant source of inspiration for this work.

 

17 August, 2001. Hyderabad

Dr. Prasanta Mahapatra,   Director, Institute of Health Systems, and Strategy Development Workshop Team.

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Workshop Summary

Session-1:

Providing universal access to Primary health care and improvement of health levels in backward regions.

Key Issues discussed in this session are:

1. Prompt access to key health staff. Availability of health care profes sionals at their respective stations is a major problem.

2. Role of PHCs and Sub-centres.

3. Basic package of medical care and public health services.

Recommendations and possible actions:

1. Non availability of health care professionals at their respective centres is a problem which needs immediate attention.

2. Redefining the role of Primary Health Centres and Sub-centres. Particularly the mechanism of delivery of ambulatory medical care for the poor needs, to be worked out. Only then, it will be possible to clarify the role of PHCs.

3. It will be desirable to define basic packages of medical care and public health services, to facilitate clear cut role definition and streamline allocation of resources.

Session-2

Improving district level capacity for public health, planning and management.

The key issues highlighted in this session are:

1. Focus on the multidisciplinary human resource base.

2. Inadequate epidemiological, managerial and planning skills of existing personnel.

3. Limited capacity and authority within districts for management.

4. Limited incentives for hospitals.

The following are the possible actions and recommendations:

1. The need for strengthening managerial capacity of district health teams and PHC officials was felt unanimously. Composition of district health teams should be more interdisciplinary.

2. Progress in development of managerial capacity and interdisciplinary composition of district health teams should be accompanied by increasing delegation of both financial and administrative authority. In particular, the role of District Collector and district health teams should be reviewed. District collectors will have an essential role in intersecto ral coordination and can achieve much better health care delivery system with a strengthened district health team.

3. Foundation training in the areas of public administration, public health and field epidemiology should be imparted to Medical officers.

4. District level capacity in health care programme management informa tion system should be strengthened.

5. Skills in participatory programme implementation, community mobilisa tion, etc should be emphasised by organising periodic training programmes. Other means of motivating community participation should be explored.

6. All existing district level societies created under various vertical programmes should be consolidated into a single entity.

7. Explore possible ways of empowering panchayat raj leaders and advisory committee members to understand the role of public health system and evaluate their performance.

Session-3

Financial issues.

This session drew particular reference to the following key issues:

Ÿ Resource allocation to Primary Health Centres and to non-salary expenditure.

Ÿ Inefficiency in spending on health services and the health services being captured by the better-off.

Ÿ Poor being unprotected from health shocks.

Ÿ Autonomy to hospitals

Ÿ Insurance schemes

The possible actions and recommendations are :

1. In the medium term, allocations to the health sector should be substantially increased. The current level of allocation is too low.

2. Efficiency of health care institutions should be improved to raise cost-effectiveness of services and realise higher outcomes from existing allocations.

3. More and more operational autonomy should be granted to hospi tals with clear-cut guidelines on utilisation of user fees. Clear guidelines about sustenance of budgetary support should be developed. Compensatory withdrawal of budgetary support to institutions successfully raising user fees should be avoided. Instead, clear cut understanding about sharing of user fees should be laid down.

4. Social insurance mechanisms and capitation based payment mechanisms should be explored to expand coverage of people with health care in a cost- effective manner.

5. Introduction of user fees should be accompanied by adequate provision of funds for poor and needy people. Impact of user fees on access to care by poor should be started and monitored at regular intervals.

Session-4

 

1. Harnessing the private sector and encouraging private investment in tertiary healthcare.

The issues discussed were:

• Private sector is not being exploited for provision of public health service
• Variation in quality of the private service
• Poor being exploited by the private sector
• Introduction of accreditation system
  

The feasible actions and recommendations :

1. There was a consensus about development of a system of quality assurance in both private and public sector health care institu tions (HCIs).

2. Setting up of a rate setting mechanism backed by adequate studies on costs of care, billing practices etc. can stimulate development of private sector.

3. Direct capital subsidy may be of help to develop non-profit chari table hospitals.

4. Allocations for tertiary care services in public sector should be limited. Instead allocations for programmes on quality assurance, accreditation, for rate setting, development of practice guide lines etc could help build required market for development of tertiary care facilities in private sector.

 

Session-5

Streamlining human resources for health care and capacity building:

The key issues discussed were:

• The availability of the staff at the work place
• Lack of motivation in the staff not oriented to their work and responsi bilities
• Inadequate continuing education, foundation training
• Incentives

The possible actions and recommendations include:

1. Need to study various factors affecting availabililty of health care professionals in PHCs and sub centres.

2. Measures to improve availability of personnel at the PHC and subcentres would include comprehensive review about appropri ateness of currently defined educational qualifications for deliv ery of health care services in PHCs, training of personnel, improvement of personnel management practices by senior managers, improvement of infrastructure such as housing, educa tion and communication facilities.

3. All Medical and Health officers should be provided with founda tion training in public administration, rapid assessment of local health problems, interpersonal skills, epidemiological investiga tions, management of public health programmes etc.

4. New skill combinations may be explored.

5. Developing area specific strategies, based on small area analysis of health status, and study of cultural practices. Local and regional resources should be factored into health care programmes.

Session-6

Enhancing performance of the public health system. Functional indicators and performance measurement and Prevention focus: intersectoral co-ordination and redefinition of public health roles:

There was substantial discussion in this session about the following issues:

1. Foundation / Induction training programmes for medical officers.

2. Vigilance on corrupted medical staff

3. Need for clear definition on the role of PHC officers

4. Exploring the possibility of introducing report card system

The possible actions and recommendations suggested are as follows:

1. Role of PHC officers should be clearly defined, particularly public health roles like sanitary inspection of water supply sources, required to facilitate intersectoral co-ordination. But these aspects of PHC officers' role are not well defined.

2. PHC officers should be trained to understand the role and respon sibilities of various departments, authorities and social institu tions towards matters affecting public health. Only if the PHC officers have an overview of various institutions, they can contrib ute to intersectoral co-ordination.

3. Client oriented performance assessment measures should be developed. A report card system needs to be maintained to know about the patients' satisfaction about the treatment, nursing, drug delivery system etc., which can be a sort of feedback to take action. Regular assessment of patient/client satisfaction will help identify priorities for intersectoral co-ordination.

Session-7

Optimising material resources for health care

The important issues discussed were:

• Inadequate resources for operation and maintenance of services;
• Inefficient use of resources, expensive antibiotics, equipment maintenance
• Inflexibility in use of funds.

The recommendations suggested in this session were:

1. Proper balance should be maintained between salary and non-salary allocations. Salary allocations should be between 50 and 70%. It should not exceed 70% in any case.

2. Clear distinction of resources for drugs and other non-salary items.

3. Greater flexibility to be given to the institutions for procuring material and supplies. Current policies on procurement of equip ment and maintenance of the existing equipment needs to be reviewed thoroughly.

4. Adequate resources should be allocated for operation and mainte nance of services.

5. Periodic review of the essential drugs list formulary is very much important as well as effective implementation of the Government order Ms No 277, 1993 already issued for the purpose.

Session-8

Overview and Conclusions:

This session reviewed the topics discussed and highlighted major key problems.

1. There is a need for immediate intervention on availability of health care professionals at their respective stations. There is also a need for thorough review of the role of PHCs and Sub-centres. It was felt neces sary to define basic packages of medical care and public health services, to facilitate clear cut role definition and streamline allocation of resources.

2. The need for strengthening managerial capacity of district health teams and PHC officials was felt unanimously. Progress in development of managerial capacity and interdisciplinary composition of district health teams should be accompanied by increasing delegation of both finan cial and administrative authority.

3. Need for provision of incentives for staff to work in rural areas. Founda tion training for Medical officers should be provided in the areas of public administration, public health, rapid assessment of local health problems, interpersonal skills, epidemiological investigations etc. New skill combinations may be explored.

4. Existing district level societies created under various vertical programmes should be consolidated into a single entity.

5. District Medical and Health Officers (DM&HOs) should be given flexibil ity in terms of financial powers.

6. The participants felt that initiation of the concept of user fees and insur ance is welcome, but the impact of the user fees on utilisation of services needs to be studied in greater detail. Better health care facili ties needs to be provided, targeting the services to the needy and exploring capitation based mechanism for effective functioning.

7. There was consensus about development of strategy as a system of quality assurance in both private and public sector Health Care Institu tions (HCIs).

8. Setting up of a rate setting mechanism can stimulate development of private sector. Allocations for tertiary care services in public sector should be limited.

9. Inter-sectoral co-ordination is essential to achieve much better health care delivery system with a strengthened district health team.