|Year : 2013 | Volume
| Issue : 4 | Page : 248-253
Universalizing health services in India: The techno-managerial fix
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Web Publication||18-Dec-2013|
K R Nayar
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The non-universal nature of health services in India can also be the result of many reforms and milestones the health services had passed through since independence. The reform era during the post-nineties is replete with many new trends in organizational strategies which could have led to crises in health services. The salient crises need to be dissected from a larger societal crisis and the specific crises in the health services system. It is evident that non-accessibility and non-availability and the sub-optimal functioning of the primary health centers are perennial issues which could not be addressed by indigenous, imposed or cocktail reforms (such as National Rural Health Mission) and by targeting as these only tinker with the health services. Needless to reiterate that there is a need to address the social dimensions which fall outside the technical sphere of health services. This paper based on an analytical review of relevant literature concludes that any efforts to universalize health and health-care can not only focus on technical components but need to address the larger social determinants and especially the societal crisis, which engender ill-health.
Keywords: Crises in health services, Health reforms, Social determinants, Universal health
|How to cite this article:|
Nayar K R. Universalizing health services in India: The techno-managerial fix. Indian J Public Health 2013;57:248-53
| Introduction|| |
In India, the discourse on public health has undergone considerable shifts in recent times with the emergence of a body of knowledge directed by para-state institutions, non-governmental organizations and the private sector.  This academic discourse is closer to the neo-liberal reform agenda and is a theoretical and techno-managerial. Both the reform agenda and this academic discourse assume that the problems of health and health services are the outcome of inefficiency of the government and therefore the solutions lie in reducing the role of the State and increasing the participation of private sector. However, it is necessary to review and reflect on the causes of such inefficiencies and deviations before corrections can be suggested for achieving universal health-care. We argue that either such an exercise has not been done or the available counter evidence has not been assessed or they have been ignored in favour of easier down-stream factors.
The non-universal nature of health services in India can also be the result of many reforms and milestones the health services had passed through since independence. The reform era during the post-nineties however is replete with many new trends in organizational strategies, which require analysis from a political economy perspective. The salient crisis could also be dissected from larger societal crises and the specific crises in the health services system. However, it is increasingly difficult to disentangle the co-existence of the two levels. The recent crisis in health services in India such as shortage of human resources or crumbling health services can be linked to the health reforms undertaken in developing countries which suggested disinvestment, downsizing by reducing the number of public sector employees by voluntary retirement (golden handshake); reduced recruitment of staff especially at the lower levels; increasing salary differentials between the high ranking and lower staff, which make the career in health services unattractive to the personnel.
We normally tend to consider reforms in relation to public management or administration as a neutral operation and changes needed to improve the efficiency and performance of larger systems delivering services to the people. In the history of health services development, one could discern many such instances of "neutral operations." However, in recent years the new externally-driven approach to reforms in public systems has gained notoriety given its ideological basis and conditionalities, which sometimes go against justice and the established norms of a welfare State.
Conversion of uni-purpose health workers into multi-purpose workers was one of the important reforms undertaken regarding the delivery of health services in India. Unfortunately, such a bold and timely reform process did not have a beneficial impact on the health services as the system continued to be pre-occupied with family planning activities and as the spirit of comprehensiveness was not inculcated among the multi-purpose workers.
The creation of Community Health Centers (CHCs) as the first referral units was a major milestone in the delivery of medical care in the country. The CHCs were established to reduce the hardships of the rural population for accessing specialist services, but subsequent evaluations show that even the objective of providing a referral curative care has not been achieved due to several problems. 
The Community Health Volunteer scheme (CHV scheme) is another major intervention in the history of health services development in the country to place people's health people's hands by having a representative of the community dealing with the basic health care in rural areas and serving as a link between the people. The Scheme was inspired by the Chinese barefoot doctors' scheme. The democratization of health services, the essence of CHV program, could not succeed due to the extreme bureaucratization and professionalization that prevailed within the health services apart from the hierarchical nature of the society, which got reflected in the representation of these volunteers. 
The National Rural Health Mission (NRHM) is another reform measure in the health services of India largely influenced by an endogenous process and political compulsions to mollify the disenchanted voters and a pressure from international donors to achieve the millennium development goals (MDGs).  We could observe that even the endogenously evolved reforms have slowly started absorbing the essence of exogenously driven reforms and have been adopting approaches such as public private partnerships, privatization etc. For instance, some of the propositions that we find in the NRHM are closely akin to the neo-liberal reform strategies that we find in the World Bank documents and can be called as cocktail reforms.
| The New Crises of Neo-liberal Reforms and the Problems of Access|| |
The health sector reform program, which is a corollary to the structural adjustment program, rationalizes a number of its actions based on the issues of inefficiency, spending on inappropriate and inefficient services etc. It also questions the high component of salaries in the public sector compared with operating costs. It also laments that services are inaccessible and that services are unresponsive although they are over-staffed. 
The present reform process under the structural adjustment programs also has another rationale. It is apparently undertaken in response to a fiscal crisis. Therefore, the various strategies are intended to enforce financial discipline. The first target of such financial disciplining strategies is the public sector. In order to reverse these trends, the health sector reforms have a number of components such as improving the performance of the civil service, decentralization, improving the functioning of the national ministries of health through organizational restructuring, improving human and financial resource management etc., broadening health financing options such as introduction of user fees, community financing, social insurance etc., introduction of managed competition between providers and working with the private sector.  In effect, however, what happens is not financial discipline, but delegation and privatization of services delivered through the public sector. This ideology has also influenced organization of medical education in the country. The social role of medicine is no longer relevant in the burgeoning medical education industry where mass production and profit are the main features. In the health services, this has serious implications, some of which have been discussed in a critical discourse evolved during the nineties and after. 
Withering comprehensive care
It is now well-known that the health reforms that we encounter at present are part of the global agenda that is linked to market and trade in a globalizing world.  Health sector is now being considered as an area worth investing in order to reap profits. It is also recognized that such a capital investment may not be sustainable in areas where profits may not be forthcoming, i.e., in a comprehensive approach involving preventive and primary care as well. The 1993 World Development Report foresaw this while suggesting bifurcating preventive care for the State and curative care for the private sector and defined an essential clinical package.  Such bifurcation kills the spirit of comprehensiveness of health programmes.
Another major trend in the health services inherited from the family planning program is the target-driven mode. Targeting is intended to overcome organizational weaknesses and failure in implementation. However, failure in implementation could be the result of unrealism and lack of vision at the planning stage. It also means that the complexity of the problem cannot be tackled by targeted interventions based on aggregate data as targeted interventions could lead to technological packages ignoring the larger structural dimensions of the problem. The target-driven programs can also result in intensive, vertical and categorical programs, which may distort the comprehensiveness of health services as has happened with the attempt to eradicate polio. The target driven and time-bound approaches could also place unrealistic demands on the existing fragile and crumbling delivery systems in the developing countries. Parallel and disease-specific interventions, which may emerge from the need to meet the MDGs, could result in "duplications, distortions, disruptions and distractions" within the health-care system.  Another possibility is that selective approaches could be used as an excuse to give fillip to privatization even in extremely important areas like maternity care in rural areas.  This is already being attempted in India, where there is a move to involve private corporate sector in maternity care in rural areas in the name of reducing maternal mortality rate (MMR), which could result in increasing the inequity in health-care. Long-term, broader, system-based interventions through an integrated approach could be more cost-effective, result-oriented and beneficial compared with such intensive drives especially in a context riddled with wider social disparities and inequities.
There is considerable evidence now from the National Family Health Surveys (NFHSs) that differentials still persist between the upper castes and the lower caste groups including scheduled tribes and scheduled castes in India regarding accessibility and availability of health-care services such as immunization, maternity care etc.  It is evident that non-accessibility and non-availability and the sub-optimal functioning of the primary health centers are perennial issues, which could not be addressed by indigenous, imposed or cocktail reforms (such as NRHM) and by targeting as these only tinker with the health services. Needless to reiterate that there is a need to address the social dimensions, which fall outside the technical sphere of health services.
| The New Doctrines and the Old Crisis in Health Care|| |
The new ideas and doctrines on organization of public services based on the logic of planned markets have largely come from donor agencies like the World Bank and the Asian Development Bank and specialized U.N. agencies like the World Health Organization (WHO). These are often couched in technical and management language, which appeal to generalist administrators and often thrown in as indicative options rather than prescriptions.  These are largely unquestioned assumptions based on certain strategic principles of the donor agencies. Most of the reforms are intended to make public organizations more like firms operating in markets.  These assumptions are based on the notion that developing countries lack the necessary infrastructural and managerial resources to deliver public services.
The new public management (NPM), an Anglo-American product has been the core approach behind this move. The NPM essentially is a value-for-money approach which suits the donor agencies and it is known in different names such as, modernising government, management by objectives etc. For the proponents of NPM, the reforms are intended to increase efficiency by improving input-output ratio within the public sector. It also purports to improve accountability and transparency within the system.  Partnership is also a key word within the NPM strategy under which the main thrust will be public-private partnerships. One of the implicit objectives of NPM is to reduce political control of decision-making and increase the role of managers. It also involves "lean thinking," the purpose of which is to put in place systems and processes that minimize the n decision points.  Often NPM strategies lead to celebration of universal managerial solutions informed by market-based ideology. For instance, the current fad on convergence results in universal frameworks with little respect for contexts, cultures or traditions. 
Apart from downsizing, some of the strategies under new reforms include restoring key elements of a traditional bureaucracy such as order, hierarchy and accountability etc. It also includes contract management by contracting out some key services to the private sector, creation of autonomous organizations such as health corporations and societies as in acquired immunodeficiency syndrome control, introduction of user charges etc.
In general, cost-sharing and risk-pooling initiatives had a negative impact on accessibility and utilization health services in poorer countries. The frequency of use of medical services decreased significantly almost everywhere after the implementation of cost-sharing measures such as user fees.  There is an abundant array of evidence, which shows that people with highest need of medical services such as poor and people suffering from communicable diseases could not afford out of pocket expenditure.  User charges also affect the access of women and low-income groups to basic services. Clearly then, there is a need to rethink about the utility of these strategies in the delivery of health-care in India. Organization for Economic Co-operation and Development and WHO advocate free primary-level services; free services for targeted groups or communities; free services for priority diseases or conditions; exemption systems for hospital services; charges for the use of tertiary care by those who can afford it. 
The new approach to public sector management and especially public sector health services is a near total deviation from the earlier administrative principles based on equity, equality and epidemiology to one, which are market-driven aimed at gradual downsizing of public sector health services. There is no doubt that this will create vast gaps and chasms within the population and demolish the democratic traditions in health services.
| The Society in Crisis|| |
The larger societal crises in India emerge from the super imposition of the new international capital on a society with wider social differentials. Utsa Patnaik argues, based on the National Sample Survey data that withdrawal of subsidies in agriculture and inability of small and marginal farmers to maintain their livestock as a result of a rise in livestock product price led to increase in landlessness and to enormous loss of livestock. She says that this is not a short-term problem but has been created by an attack on the basic structure of production and the agricultural economy including sharp reduction in public planned development expenditure in rural areas. This agrarian crisis in what she calls as the "Republic of Hunger"  has also resulted in massive decline in the food grain availability per head from 177 kg in the 1990s to 153 kg in 2003-2004, which is unusual in normal times and not under conflict or disaster conditions. She says that this is a little lower than the 157 kg level during 1937-1941. She also reports that only sub-Saharan African countries and least developed countries have lower level than this. Neo-liberal reforms have targeted both production and access and such policies have affected the incomes of the farmers thereby also resulting in less employment for the agricultural labour. , It is quite evident that a larger societal crises in India is created by exogenous forces and mediated by indigenous political class. The direct implication of such a crisis on the health of the poor needs no elaboration.
Persisting social disparities
The macro economic scenario has to be contextualized in terms of the persisting disparities and health differentials in the country and the strategies to address these issues through the health services. There is increasing evidence that strategies and organizational structures that work well in market economies may not be appropriate in low-income countries.  Division of existing comprehensive approach into curative and preventive care and entrusting them with private and public sectors respectively, encouraging privatization or even a public-private mix, other forms of managerial practices intended for cost recovery etc., may in fact lead to negative fallouts in a society riddled with mass poverty and social inequalities such as extreme stratification based on caste and gender. The debates on reforms that have emerged in recent years are not just limited to the contextual differences, which are certainly important as against a globalised vision, but even focus on the need to take into cognizance societal structures especially given the close linkages between social dimensions and health. There is already enough data to substantiate disparities between different social groups in India with regard to health. It appears that these disparities are persistent even in the post-reform era when claims are made about an all-around shining economy [Table 1]. The health status and utilization patterns of social groups give an indication of their social exclusion as well as an idea of the linkages between poverty, class and ill-health (NFHS, I, II and III). Income differentials in terms of health status are also very glaring. For instance, infant MR is 70 in households in the lowest wealth quintile, 58 in the middle quintile households and 29 in the highest wealth quintile households. 
| Conclusions|| |
One can state unequivocally that health and health services have a bio-medical/technical dimension although any efforts to universalize health and health-care can not only focus on technical components, but address the larger social determinants and especially the societal crisis which engender ill-health. The present crises and non-universal nature of health and health services is multifaceted as evident from the review undertaken in this paper and pointed out by many other scholars.  Acting on the interface between health-care crises and societal crises could be the key to universal health. For decades it is known based on the experience of some states in India and other countries that universal health is closely linked to inter-sectoral actions and universal health-care was only one of the factors responsible for better health.  The Indian Council for Social Science Research-Indian Council for Medical Research report on health for all which was probably the only report produced by the union of social and medical sciences had a progressive vision for addressing issues related to both the society and the health services  The report adopted a comprehensive definition of health and placed it in the context of socio-economic transformation. From the social determinants point of view and for an appropriate strategy for universalizing health-care, the committee had a clear vision of health as an integrated development, which can eliminate poverty and inequality, spread education and can enable the poor and under-privileged to assert themselves.
Despite such clarity regarding universal health-care and a broader and appropriate conceptualization, universal health is normally operationalized in terms of provision of care and services and the critical areas for achieving it such as financing, norms, human resources, community participation, access to medicines, vaccines and technology, managerial reforms etc., are also service-oriented and largely proximal.  There are also dangers in giving too much preeminence to services over inter-sectoral factors. Given the thrust on industry and private players apart from the state for the provisioning of health-care, further withdrawal of the state is a possibility even if the outlay for health is increased. The Public-Private Partnership in the NRHM is largely a model of delivering health-care initiated without much critical scrutiny.  Apart from facilitating further withdrawal of the state from health care, there is also a danger of the public money going into private hands in such a model. These are some of the managerial fixes that need to be scrutinized critically. Furthermore, the danger of universalization through existing institutional strategies and framework turning into an upper-class oriented health service model is another possibility that has to be kept in mind. This is especially since approaches to universal health-care is different from universal education or universal food program considering the technological (bio-medical), financial and institutional character of health-care.
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