Declining free healthcare and rising treatment costs in India: an analysis of national sample surveys 1986-2004

The article focuses on trends in health-seeking behaviour of people and choosing between government and private sources, reasons for not accessing health care and the cost of treatment by examining three rounds of NSS data on health care use and morbidity pattern during 1986–87, 1995–96 and 2004. With variation across states, treatment-seeking from public providers has declined and preference for private providers has increased over the period. Although overall health-seeking behaviour has improved for both males and females, a significant percentage of people, more in rural than urban areas, do not seek treatment due to lack of accessibility and consider that the illness is not serious enough to require treatment. The financial reason for not seeking treatment was also an important issue in rural areas. There has also been change in the cost of health care over time. While the health care cost has increased, the gap between the public and the private has reduced, owing to perhaps increased cost of treatment in public health facilities following the levying of user-fees and curtailing distribution of free medicine. Practically all states reported decline in availability of free both out-patient and in-patient care. The article concludes with supporting the adaptation of innovative public-private partnership in health sector for various services realizing the limitations of the state provision of health, particularly in rural and remote areas, and the growing preference of consumers for private health providers. As effectiveness of public spending also depends on the choice of health interventions, target population and technical efficiency partnering with private health providers could work towards reducing the health inequalities in the country

How are gender inequalities facing India’s one million ASHAs being addressed? Policy origins and adaptations for the world’s largest all-female community health worker programme

Background: India’s accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations. Methods: We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper’s government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens. Results: Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation

Parallel Systems and Human Resource Management in India's Public Health Services: A View from the Front Lines

There is building evidence in India that the delivery of health services suffers from an actual shortfall in trained health professionals, but also from unsatisfactory results of existing service providers working in the public and private sectors. This study focusses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism, which can adversely affect service delivery processes and outcomes. The paper considers four human resource management subsystems: postings, transfers, promotions, and disciplinary practices. The four subsystems are analyzed from the perspective of front line workers, that is, physicians working in rural health care facilities operated by two state governments. Physicians were sampled in one post-reform state that has instituted human resource management reforms and one pre-reform state that has not. The findings are based on quantitative and qualitative measurement. The results show that formal rules are undermined by a parallel modus operandi in which desirable posts are often determined by political connections and side payments. The evidence suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. These systems appear so entrenched that reforms have borne no significant effect