HEALTH INFRASTRUCTURE IN THE PUBLIC SECTOR

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Issues in regard to public and private health infrastructure are different and both of them need attention but in different ways. Rural public infrastructure must remain in mainstay for wider access to health care for all without imposing undue burden on them. Side by side the existing set of public hospitals at district and sub-district levels must be supported by good management and with adequate funding and user fees and out contracting services, all as part of a functioning referral net work. This demands better routines more accountable staff and attention to promote quality. Many reputed public hospitals have suffered from lack of autonomy inadequate budgets for non-wage O&M leading to faltering and poorly motivated care. All these are being tackled in several states are part health sector reform, and will reduce the waste involved in simpler cases needlessly reaching tertiary hospitals direct These, attempts must persist without any wavering or policy changes or periodic denigration of their past working. More autonomy to large hospitals and district public health authorities will enable them to plan and implement decentralized and flexible and locally controlled services and remove the dichotomy between hospital and primary care services. Further. most preventive services can be delivered by down staging to a public health nurse much of what a doctor alone does now. Such long term commitment for demystification of medicme and down staging of professional help has been lost among the politicians bureaucracy and technocracy after the decline of the PHC movement. One consequence is the huge regional disparities between states which are getting stagnated in the transition at different stages and sometimes, polarized in the transition.    Some feasible steps in revitalizing existing infrastructure are examined below drawn from successful experiences and therefore feasible elsewhere,

Feasible Steps for better performance:

The adoption of a ratio based approach tor creating facilities and other mpuls has led lo shortfalls estimated upto twenty percent. It functions well where ever there is diligent attention to supervised administrative routines such as orderly drugs procurement adequate O&M budgets and supplies and credible procedures for redressal of complaints. Current PHC CHC budgets may have to be increased by 10% per year for five years to draw level. The proposal in the Draft NHP 2001 is timely that State health expenditures be raised to 7% by 2015 and to 8% of State budgets thereafter. Indeed the target could be stepped up progressively to 10% by 2025. it also suggests that Central funding should constitute 25% of total public expenditure in health against the present 15%. The peripheral level at the sub center has not been (and may not now ever be) integrated with the rest of the health system having become dedicated solely to reproduction goals. The immediate task would be to look deepening the range of work done at all levels of existing centers and in particular strengthen the referral links and fuller and flexible utilization ofPHC/CHCs. Tamil Nadu is an instance where a review showed that out of 1400 PHCs 94% functioned in their own buildings and had electricity, 98% of ANMs and 95% of pharmacists were in position. On an average every PHC treated about 100 patients 224 out of the 250 open 24 hour PHCs had ambulances. What this illustrates is that every State must look for imaginative uses to which existing structures can be put to fuller use such as making 24 hours services open or trauma facilities in PHCs on highway locations etc.

The persistent under funding of recurring costs had led to the collapse of primary care in many states, some spectacular failures occurring in malaria and kalazar control. This has to do with adequacy of devolution of resources and with lack of administrative will probity and competence in ensuring that determined priorities in public health tasks and routines are carried out timely and in full. Only genuine devolution or simpler tasks and resources to panchayats, where there will be a third women members- can be the answer as seen in Kerala or M.P. where panchayats are made into fully competent local governments with assigned resources and control over institutions in health care.  Many innovative cost containment initiatives are also possible through focused management - as for instance in the streamlining of drug purchase stocking distribution arrangements in Tamil Nadu leading to 30% more value with same budgets.

The PHC approach as implemented seems to have strayed away from its key thrust in preventive and public health action.  No system exists for purposeful community focused public information or seasonal alerts or advisories or community health information to be circulated among doctors in both private practice and in public sector. PHCs were meant to be local epidemiological information centers which could develop simple community.

Tertiary hospitals had been given concessional land, customs exemption and liberal tax breaks against a commitment to reserve beds for poor patients for free treatments.  No procedures exist to monitor this and the disclosure systems are far from transparent, redressal of patient grievances is poor and allegations of cuts and commissions to promote needless procedure are common.

The bulk of noncorporate private entities such as nursing homes are run by doctors and doctors- entrepreneurs and remain unregulated cither in terms of facility of competence standards or quality and accountability of practice and sometimes operate without systematic medical records and audits. Medical education has become more expensive and with rapid technological advances in medicine, specialization has more attractive rewards. Indeed the reward expectations of private practice formerly spread out over career long earnings are squeezed into a few years, which becomes possible only by working in hi tech hospital some times run as businesses. The responsibilities or private sector in clinical and preventive public health services were not specified though under the NHP 1983 nor during the last decade of reforms followed up either by government of profession by any strategy to engage allocate, monitor and regulate such private provision nor assess the costs and benefits or subsidization of private hospitals. There has been talk of public private partnerships, but this has yet to take concrete shape by imposing pubic duties on private professionals, wherever there is agreement on explicitly public health outcomes. In fact it has required the Supreme Court to lay down the professional obligations of private doctors in accidents and injuries who used to be refused treatment in case of potential becoming part of a criminal offence.

The respective roles of the public and private sectors in health care has been a key issue in debate over a long time. With the overall swing to the Right after the 1980s, it is broadly accepted that private provision of care should take care of the needs of all but the poor. hi doing so, risk pooling arrangements should be made to lighten the financial burden on theirs who pay for health care. As regards the poor with priced services. Taking into account the size of the burden, the clinical and public health services cannot be shouldered for all by government alone.   To a large extent this health sector reform m India at the state level confirms this trend. The distribution of the burden, between the two sectors would depend on the shape and size of the social pyramid in each society. There is no objection to introduce user fees, contractual arrangements, risk pooling, etc. for mobilization of resources for health care. But, the line should be drawn not so much between public and private roles, but between institutions and health care run as businesses or run in a wider public interest as a social enterprise with an economic dimensions. In a market economy, health care is subject to three links, none of which should become out of balance with the other - the link between state and citizens' entitlement for health, the link between the consumer and provider of health services and the link between the physician and patient.