Equity concerns for health

Equity concerns for health

Dr Md Rajja

The indicators of health sector reform initiatives are discernable when the government offered direct concessions to the private sector and these have to include permission to foreign providers of medical cares to operate in South Asia, encourage private health insurance industry, to lease spare capacity in public facilities to private practitioners, offer concessional loans to private practitioners to establish practice in rural areas. Among all the South Asian countries, India has the largest private sector and is an exporter of tertiary corporate health care to others in the region. The growth of institutions in the private sector presents a varied picture across countries. While Bangladesh, Pakistan and Sri Lanka have a very small presence of institutions at the secondary and tertiary levels, India has a fairly large private sector at these levels, marked by regional variations. In South Asia there is plurality in provisioning and utilisation at different levels of care. For minor illnesses, treatment consists of simple herbal preparations or analgesics. For chronic ailments, there is greater resort to traditional healers and ayurvedic practitioners.Urban middle classes use the private facilities more than government facilities while the urban poor utilise the facilities of government hospital, especially if it was accessible. In rural areas the use of private hospitals was slightly less than private doctors. In India, states where there is a sizeable presence of the private sector, the middle and upper income groups have largely moved out of public services and it is the poor who rely on private services much more. Medical officers and other technical officers within the state health sector practice privately, outside their working hours. In the remaining countries government doctors were allowed to practice privately and there was no effort to regulate or ban it. Even the nascent private sector was unregulated and therefore grew in a haphazard and uncontrolled manner. The consequences of rapid privatisation during the 1980s and 1990s are much more significant in India, Pakistan and Bangladesh as compared to Sri Lanka. In Bangladesh, there was a steady growth of institutions and manpower until the late seventies, after which the data shows stagnation in the growth of facilities. While there was an expansion of facilities until the eighties, the decline in investment resulted in a shortage in availability of facilities, personnel and supplies. As far as training of doctors and paramedical personnel was concerned, the state started encouraging the establishment of private medical colleges. This meant that those trained in private colleges were interested in finding jobs in the private sector. This kind of a trend is seen in India as well. Some recent trends show a shift in terms of the appointment and also training of personnel. Several states within India have been appointing doctors on a contract basis in order to overcome the shortage of personnel in rural areas. There is a shortage of paramedical workers as well due to a freeze on training and recruitment of various categories of these workers. The solution to this impasse has been to introduce multi skilling of existing workers or to encourage community health workers on a voluntary basis with a small honorarium. Health sector reform in South Asia presents certain common trends but also variations in terms of the political economy and health services development in the four countries. Soon after independence the governments of all the four countries had committed themselves to investing and building a welfare state governed by principles of equity and social justice. Except Sri Lanka, which managed to build a universal and free welfare service, the others did not make the required investments in the welfare sector, especially health. The global recession during the late seventies had an adverse impact on public spending and this resulted in either a cutback or stagnation in investments in health across all these countries. This had serious consequences for public services and in fact created spaces for the growth of the private sector. During this period there was a shift in policy in favour of privatisation by offering concessions and subsidies to encourage the private sector, across all the countries in the region. Privatisation in highly inequitous societies like South Asia is bound to marginalise access to the lower middle and poorer sections, which constitute around 30-60 per cent of the population. Available studies on the utilisation of services in India and Sri Lanka show that the middle class has largely moved away from public provisioning in favour of profit care and it is the poor who use public services. The indirect costs for even publicly provided services are increasing and there is evidence that there may be section of the population who may not be able to afford even these services. Equity concerns are very important at this juncture for health policy. Since the middle classes have moved out of public provisioning, the principles of universality have also been gradually undermined. Therefore the concern for public health derives not only from the excessive growth of for profit market based health care, but also from the differential state of public services across the region.

Dr Md Rajja

Medical Doctor

Birgunj Nepal

Email: arnold_raza@yahoo.com