Content uploaded by Siddharth Agarwal
Author content
All content in this area was uploaded by Siddharth Agarwal on Aug 03, 2017
Content may be subject to copyright.
Content uploaded by Siddharth Agarwal
Author content
All content in this area was uploaded by Siddharth Agarwal on Apr 02, 2016
Content may be subject to copyright.
HEALTH SECTOR REFORM AND ETHICS
Public-Private Mix: a Public Health Fix?
Strategies for Health Sector Reform in South and Southeast Asia
International Workshop
20-22 June 2007
Naresuan University, Phitsanulok, Thailand
WORKSHOP REPORT
Rapporteurs:
Siddarth Agarwal
Rama Baru
Nupur Barua
Kira Fortune Jensen
Jenifer Lobo
Jens Seeberg
Yati Soenarto
WWW.HUM.AU.DK/HSRE
1
Table of Contents
List of abbreviations.................................................................................................................................. 3
Introduction............................................................................................................................................... 5
The workshop............................................................................................................................................ 6
Inaugural session....................................................................................................................................... 7
Technical sessions..................................................................................................................................... 9
Health Sector Reform and Public Private Mix?............................................................................ 9
Quality of care and dynamics of the health system (Parallel Session A) ................................... 12
Health Seeking Behaviour (Parallel Session B).......................................................................... 15
Financing and health expenditures.............................................................................................. 17
Regulation – scope and limitations?........................................................................................... 19
Professional organisations and other NGOs ............................................................................... 22
Group Work 1: Comparative Perspectives.................................................................................. 24
Government perspectives............................................................................................................ 25
Group Work 2: Country-specific Perspectives ........................................................................... 29
Closing session........................................................................................................................................ 40
ANNEX 1: Programme........................................................................................................................... 44
ANNEX 2: List of participants ............................................................................................................... 48
ANNEX 3: Group work on comparative perspectives............................................................................ 51
2
List of abbreviations
AIIMS All India Institute of Medical Sciences
ANM Auxiliary Nurse Midwife (India)
ARI Acute Respiratory Infection
AU University of Aarhus (Denmark)
AYUSH Ayurveda, Unani, Siddha and Homeopathy
BPL Below Poverty Line
CBO Community-based Organisations
CME Continued Medical Education
Danida Danish International Development Assistance
DHS District Health Services/System
DKK Danish Kroner
DRG Diagnostic Related Group
FFU Danida’s Research Council
GMU Gadjah Mada University (Indonesia)
GOI Government of India
HSRE Health System Reform and Ethics (Research project)
ICDS Integrated Child Development Scheme (India)
IEC Informaiton, Education and Communication
LV Link Volunteers
MandE Monitoring and Evaluation
MCI Medical Council of India
MoHFW Ministry of Health and Family Welfare (India)
MOU Memorandum of Understanding
NGO Nongovernmental Organisation
NRHM National Rural Health Mission (India)
NU Naresuan University (Thailand)
NUHM National Urban Health Mission
3
OPD Outpatient Department
ORS Oral Rehydration Solution
PHC Primary Health Care/Centre
PNC Prenatal Care
PP Private Practitioner
PPM Public-Private Mix (or Public-Private-People Mix)
PRI Panchayati Raj Institution (local government, India)
QMP Qualified Medical Practitioner
RCH II Second phase of the Reproductive and Child Health Program (India)
RMP Registered Medical Practitioner (in India, may not be formally medically
qualified)
RUF (Former) Research Council of Danida
SEARO South-East Asia Regional Office (of WHO)
SLI Standard of Living Index
U5MR Under-five Mortality Rate
UC Universal Coverage Scheme (Thailand)
UHC Urban Health Centre (India)
UN-HABITAT United Nations Human Settlements Programme
USD United States Dollar
WHO World Health Organization
4
Introduction
This document reports the proceedings of a research-to-policy workshop that was organized as part of a
multi-country cross-disciplinary research project on the private health care sector in urban poor
neighbourhoods in India, Indonesia and Thailand, entitled "Health System Reform and Ethics: Private
Practitioners in Poor Urban Neighbourhoods in India, Indonesia and Thailand". The project consisted
of a combination of medical anthropological research among private (for-profit) practitioners and
among people living in poor urban neighbourhoods; a health economics study among poor urban
households and a desk study that assessed existing regulations and ethical guidelines in the three
countries. The project period was April 2004 to December 2007.
A number of other studies in the past have shown that the role of the private sector can be problematic,
perhaps even more so in India than in the other participating countries. At the same time, there has been
a push of public-private partnerships. The workshop intended to discuss the rationale, the benefits and
limitations and risks of this strategy. Even if there are examples of successful partnerships that serve
sound public health purposes, such partnerships may not address the structural problems that establish
effective access barriers for the poor. Based on research that provided a critical assessment of the role
of the private sector the workshop should develop relevant strategies to address public health problems
related to the role of the private-for-profit health sector. The overall purpose of the project was to
identify viable strategies for strengthening ethical practice in the private healthcare sector in poor
neighbourhoods through feasible and locally acceptable control mechanisms and other possible means.
It was believed that this is only possible through a combined understanding of patients’, private
practitioners’ and drug vendors’ perspectives. Health ethics, in this connection, may be broadly
understood as a consensus-based normative regulatory framework that primarily works to protect
patients against iatrogenic adverse events when utilizing the health system. The existing scientific
literature shows that a framework of this type is not in place, or is not working to the desired effect, in a
number of countries in South- and Southeast Asia.
The project consisted of four sub-studies that complemented each other in order to give a detailed and
multi-faceted understanding of the local health systems under study:
5
1) Existing regulatory mechanisms, including ethical codes and legislation with direct implications
for general private practitioners: desk study
2) Health systems ethics among private practitioners: ethnographic sub-study
3) Family-level treatment and health-related decision-making: interview sub-study
4) Household survey: health economics sub-study
The project was funded by the Danida Council for Development Research (RUF, after 2006 renamed to
FFU) with a budget of four million DKK covering a period of three years (2004-07).
Further information about the project is available at www.hum.au.dk/hsre.
The workshop
During 20-22 June 2007, a 3-day workshop was held at Naresuan University, Phitsanulok, Thailand, to
disseminate findings of this and related research in the region and develop policy implications. On Day
One, research findings and recommendations was discussed; On Day Two, the focus was on
comparative perspectives across the participating countries; and on Day Three, country-specific policy
recommendations were developed on the basis of the previous days' work. The workshop progamme is
attached as Annex 1.
The objectives of the workshop were:
• To identify feasible regulatory mechanisms and strategies for the private healthcare sector to
improve quality of care for the poor in urban India, Indonesia and Thailand
• To identify lessons learnt and best practices from health policy interventions for the urban poor
in the three countries
6
Inaugural session
Professor Supasit Pannarunothai, Dean, School of Medicine, Naresuan University, opened the session.
He stressed that this hospital provided services for the poor and worked with networking mechanisms
throughout the community. The objectives of the workshop primarily addressed the need to improve
quality of care for the urban poor. Participants came from six countries and constituted a fruitful
mixture of policy-makers, researchers and practitioners.
President of Naresuan University, Mondhon Sanguansermsri, welcomed the participants. He stressed
the role of Naresuan University as a progressive university that emphasised health ethics as a key issue
and that valued international collaboration. He then wished participants a good meeting.
Jens Seeberg. Assoc. Professor, University of Aarhus, then delivered his introductory remarks. He
noted that it was a rare opportunity for a research project to be able to organise this kind of research-to-
policy meeting and he thanked Danida for funding the project and the meeting. He then took the
audience back to an earlier WHO-project on ethics in South-East Asia that had led to the current
project. A regional research group was gathered to focus on the private sector. He noted that the private
sector encompassed more than private doctors, i.e. insurance companies, private medical colleges,
production and distribution of drugs, and others. All these components, he said, are complex and
require careful consideration. Moreover, there are many different types of health providers. He stressed
the need to conceptualise competing health systems and raised the question whether we need to
abandon the concept of system in this context and replace it with a notion of health networks. He
pointed out that little research had been conducted on the private sector when the World Bank strategy
to down-size government funding of health care had been launched in the late 1980s. Twenty years
down the line we still had limited knowledge of private sectors. He asked, where is the trade-off in
government funding to ensure quality of the private sector through stewardship versus investment in
government sector delivery? He then introduced the workshop by saying that the first day was
dedicated to presentations and discussions. Group work sessions would develop comparative
7
perspectives on the second day and the final day would formulate country-specific recommendations.
He stressed the shared interest in public health among all participants and said that mutual and
progressive learning would be a key outcome of this workshop. Dr. Seeberg ended his address by
expressing his gratitude to the local organisers.
Special Guest of Honour, Dr Samlee Plianbangchang, Regional Director, WHO (SEARO), then
delivered the inaugural address. He appreciated that the subject of public-private mix was being
revisited. He said there is no fixed formula for public-private mix. It depends on the country context.
The government alone may not be responsible for providing health care for the poor; government
partnerships with the private sector were necessary to ensure accessibility for the poor, but steps were
necessary to ensure access to affordable and quality services.
Dr Samlee said it was timely to revisit primary health care with a focus on the urban setting. If properly
designed and implemented, private health care may help to close the gap that currently exists because
of the lack of financial resources. He said that private health care must be initiated and promoted by the
government to meet the needs of all. Primary health care is the protection of any population’s health. In
most cases, governments should have a scheme for the poor ensuring that they are insured. Private
sector should also participate in the promotion of health in the community. He stressed that the health
services are dealing with human beings and those involved must be awarded and fully equipped with
the moral and ethical issues surrounding their responsibilities. Ethics is a challenge and there is a need
to put ethics into practice. Medical practitioners should be role models for the young people and the
next generation should ensure that the needs of the urban poor are met. Primary health care can reduce
the illnesses of the poor and make all people healthier. Private sector can make a contribution in
addressing primary health care. All people have the right to be free from all illnesses and primary
health care should be practised not only at the primary, but also at the secondary and tertiary level. Dr
Samlee ended his address by noting that the findings of this workshop would contribute to our
understanding of the current challenges as well as best ways of addressing those.
8
TECHNICAL SESSIONS
DAY 1 (20 June 2007)
Health Sector Reform and Public Private Mix?
Chair: Supasit Pannarunothai
Rapporteurs: Jenifer Lobo and Yati Soenarto
Dr. Chandrakant S. Pandav, after invoking the blessings of Ganesh for the workshop, said that India
reviews and plans its health policy at intervals of 5 years. In the 8th 5 year plan (1992), the first health
sector reform became evident when the concept of free medical care was revoked while commitment
for free or subsidized care for the needy (BPL) population was ensured. User charges were also
introduced. The 9th plan looked at the convergence between public, voluntary and private participation
in provision of health care, community participation, and accountability of the health sector. In the 10th
plan, reform focused on primary, secondary and tertiary health care, and emphasis was on equity,
financing of health care and social health insurance for the BPL population. The National Rural Health
Mission was introduced and towards the end of the plan period the addition of the National Urban
Health Mission was introduced, recognizing the presence of urban poor and the presence of private
practitioners of all varieties in these areas.
Health service reform has as yet no accepted definition, Dr. Pandav said. This adds to the problem of
initiating change. Two definitions which appeared usable were given: “Sustained purposeful change to
improve the efficiency, equity and effectiveness of the health sector” (Peter Berman,1995) and
“Defining priorities, refining policies and reforming the institutions through which those policies are
implemented” (Cassels,1997).
9
Dr Pandav outlined Health Services Reform as dealing with issues of Equity; Effectiveness; Efficiency;
Quality; Sustainability; Defining priorities; Refining policies; and Reforming institutions for policy
implementation. The need for moving to action as soon as possible was stressed.
Professor Laksono Trisnantoro explained that Indonesia has no history of planned health system
reforms. Certain facts were presented: public health expenditure was 25% of the total health
expenditure; 75% was private finance; 75% of the income of government doctors was from private
practice which was not allowed; there was no control with medical practitioners; there was inequitable
distribution of health care; and there was collusion with pharmaceutical companies.
On this background, health sector reforms were triggered by three Acts: Decentralization Acts, 1999
and 2004, Medical Practice Act 2004 and Social Security Act, 2004. Prof Laksono said that the acts did
not affect the health scenario as it was difficult to implement the acts to control the private and public
practitioners. There was a disparity in the economic status of the specialist and the general
practitioners. The inequitable distribution of health care continued. He said that the Social Security Act
was a reactive intervention to protect the poor due to the nationwide economic crisis in 1997. Prof
Laksono presented a scenario analysis, where the worst case scenario involved failure to implement the
Social Security Act and simultaneous rejection of the Medical Practice Act. To reduce the risk of
ending up with the worst scenario, he recommended the following: 1) a cultural approach should be
implemented to change medical doctors’ way of life; 2) regulation to control the private health care
sector should be developed alongside with cultural change; 3) a mixed approach of welfare state and
market-driven policy should be put on the agenda of health system reform.
Dr. Pongpisut Jongudomsuk initially introduced Thailand as a lower middle-income country. The
health indicators of the country were better than average for this group except in terms of human
resources for health. The proportion of the poor used to be very high - 42 percent of the total population
in 1988 - but declined with the gradual economic growth in the country. The majority of the poor lived
in the northeastern region while only a small proportion, 0.5 per cent, was in Bangkok. The
Government had previously introduced specific schemes for the poor. These were a) Low Income
Scheme for those below the poverty line, b) Fee Exemption Scheme for public health facilities and c)
10
Health Care Scheme as part of the PHC strategy. As a result of these schemes there were problems of
unacceptable quality of care for the poor, discrimination and social stigma.
The Universal Coverage Scheme was launched in 2002 to ensure access to care as a basic right for the
entire population. Since it was a comprehensive package, exclusions were minimal. The main
contractor was primary care providers. Private providers could participate voluntarily, but problems
between the public and private care providers did occur. Dr Pongpisut concluded that the Universal
Coverage Scheme is a pro-poor scheme although its nature is universal coverage. Lower utilization of
the rich may lead to relatively poor quality of service. Tax-based financing is recommended for
countries with a large informal sector to achieve universal coverage. Primary care and district health
system (DHS) favor the poor and a financing mechanism should be designed to strengthen their
functions. Increased access to care of the population may threaten a health care system with limited
human resources, and a drain of experienced medical doctors from the government to the private sector
was already happening in Thailand.
Dr Firdosi Mehta showed that the present situation in the global control of tuberculosis (TB) had
improved substantially. Prevalence of infection and death due to TB had decreased through the
implementation of DOTS. The problem in Southeast Asia is coming under control through strategic
planning for each country and appropriate action. Public-Private Mix (public-private, private-private,
public-public) enable partnerships to be developed for delivery of care for TB control. Evaluation of
PPM initiatives have shown that good treatment outcomes do occur. The benefits of PPM were
enhanced quality of TB management and care, decreased financial burden, cost effectiveness etc. The
functions of the public and private providers needed to be delineated in order to make this strategy
work. The role of PPM in the control of TB could provide lessons for future policy in other areas of
health. A detailed example of PPM helping TB control through DOTS was given, where the private and
public providers and the TB program collaborated to ensure that DOTS was implemented.
Professor Reidar Lie stressed the role of basic ethical values and human rights to guide health policies.
The right to health means that health care has to be accessible to all. Yet there was a realization that
economically weak countries would not be able to ensure equal rights to health for all citizens. This
gave rise to the fairly popular notion, promoted by the World Bank and WHO, that there was a right
11
not to comprehensive health coverage, but only to a basic or essential package. But it was essential that
improvements in economic status of the countries should be reflected in changes in health policy.
While the human rights framework could not be used to prioritize one specific treatment type over
another, Professor Lie noted that a human rights framework for health sector reform was needed to give
direction to policy development, since differential access to health care was intrinsically unjust and
governments should be made accountable for overcoming such inequalities. He stated that one cannot
accept a system that as a principle accepts that one group of people receive access to a higher level of
services than other groups.
Quality of care and dynamics of the health system (Parallel
Session A)
Chair: Dr. Pongpisut
Rapporterurs: Rama Baru and Jens Seeberg
Jens Seeberg’s presentation was based on the findings of the study of private health care delivery in
Bhubaneswar, Orissa. Dr Seeberg pointed to the rapid growth of the private sector during the 1980’s
and the role of the World Bank that initially promoted this growth more in order to downsize
governments rather than based on evidence regarding the private sector. The downsizing of
governments has created benign conditions for the growth of the private sector. While referring to the
private sector, he said that a distinction needs to be drawn between the ‘for-profit and non-profit’
sectors. In the former there are both informal and formal providers. The formal sector not only consists
of providers but also includes production, sale and distribution of drugs and technology. In this
scenario, the state has an important role in dealing with licensing. This study focused on these aspects
in Bhubaneswar, which he divided into centre and periphery. He listed all available facilities at the
primary, secondary and tertiary levels. The structure and behaviour of the pharmaceutical industry and
its interface with providers and the medical representatives as mediators between the producers, service
providers and consumers was discussed. The study showed that fierce competition between
pharmaceutical companies led to use of aggressive marketing strategies that was implemented by
12
medical representatives. The key role of the chemists, how they do not have trained pharmacists and
how they act as informal agents for the pharmaceutical industry was delineated. Here, the
pharmaceutical companies have deeply entrenched themselves by exploiting the weaknesses of the
private sector. While the state has a key role in certification, regulation etc., it was found to be very
porous and ineffective, particularly in dealing with the pharmaceutical sector. Dr. Seeberg’s
suggestions for reform included promotion of transparency in government licensing and control
activities, establish control mechanisms for drug promotion in collaboration with the pharmaceutical
industry, to establish free primary health care services in urban and peri-urban areas, and to ensure that
migrant populations have access to such services.
Rama Baru took as point of departure for her presentation the widespread use of private practitioners
for outpatient services and linked that to issues of location and distribution mediated by the
socioeconomic characteristics of the population served. The growth of the private sector at secondary
and tertiary health care levels is largely an urban phenomenon, and there is a clear class gradient in
terms of utilization of public and private hospitals. Pointing to the existence of so-called Registered
Medical Practitioners (RMPs), many of whom may have little formal education and training in
biomedicine, Dr. Baru said that little had been done to integrate them and upgrade their qualifications.
On the contrary, the Indian Medical Association had classified them as quacks and campaigned against
them. She pointed to a study showing that most had completed high school and that most had an
apprentice relation with qualified medical practitioners, to whom they also refer patients. They tend to
use the same equipment as QMP, and they provide the same symptomatic ‘cocktail’ treatment that
many QMPs give in order to ensure patient satisfaction. Dr. Baru went on to discuss the heterogeneity
of the private sector at secondary and tertiary levels. In terms of reform of the sector she insisted on a
systemic perspective that should look at both the formal and the informal sectors that are organically
linked. Regulation is important but cannot be implemented by the government alone. There is a need
for self-regulation as well. The NRHM provides a window for policy initiatives. She stressed the need
to expand this mission beyond poor districts to cover the entire country and to address issues at
secondary and tertiary care levels as well, including plugging the private practice of government
doctors.
13
Roy Tjiong presented a brief overview of health service delivery, health programmes and current health
status in Indonesia. The MMR and IMR were high and there is a double burden of communicable and
noncommunicable diseases. The available data shows that there is inequality in health status across
regions and different income quartiles. As compared to other countries in the region, Indonesia fares
poorly with respect to IMR, MMR and malnutrition levels. Data on utilization patterns show that the
poor do utilize the public facilities. Only around 55% use allopathic services while a large proportion
still depend on traditional healers and other informal practitioners. Indonesia has low investments in
health; therefore, 88% of health expenditure is out of pocket.
Chorrul Anwar from Indonesia made a presentation on the policy initiatives undertaken to regulate the
private sector in Jogjakarta. He enumerated the difficulties in the policy process in order to ensure the
provision of good quality care. He identified the pluralism of the health sector as involving a problem
of ensuring quality of care. Rules and regulations are not strictly enforced and are often violated. Some
doctors practice without license or with other doctor’s license. They may dispense medicines and act as
drug distributor. Some nurses practice without license and dispense drugs. Some traditional healers
provide medical treatment. Some of these irregularities are in accordance with patient demands, since
people prefer providers who dispense rather than prescribe drugs. There is a need to strengthen
regulation through licensing, certification and accreditation, including all types of systems. In addition
there is a considerable amount of cross-practice that makes regulation difficult. He described in great
detail the steps, process and stakeholders in the regulation of private providers. Apart from these, he
also provided insight into the institutional mechanisms and bodies that have been created to set
standards for the regulatory process and to ensure monitoring and surveillance. An interesting feature
of this model is that it has space for the ‘voice’ of consumers through the creation of a
grievance/complaint redressal centre in the Mayor’s office where complaints can be lodged against
private providers/hospitals. He presented some data on the status of regulation and also pointed to the
limitations due to the long process and lack of adequate human resources to carry out all the necessary
activities. A multi-stakeholders approach involving different levels of government, professional bodies
and users of health services has been used in this process of regulation in Jogjakarta city.
14
Aumnoay Pirunsarn presented some insights from the ongoing study on characteristics and behaviour
of private providers in Phitsanulok. He showed the fairly strong presence of the private sector at all
levels of care. He pointed to how patterns of health seeking behaviour are mediated by symptoms;
period of illness, time spent waiting for practitioner and loss of income. His study showed that the drug
store or chemist is the most important player in treatment at the primary level. The attributes of a good
drug store were enumerated to include the knowledge of chemists; his ability to give advice and also to
follow up patients. The cases of general practitioners showed that they were experienced and had fairly
high patient loads.
There was a lively discussion following the presentations. Regulation and the varying patterns across
countries were discussed. This is an area for comparative studies across countries in terms of
processes, networks used and outcomes – both in terms of successes and failures. Apart from the state
there was discussion regarding what NGOs can do to control and regulate pharmaceuticals. There was
a recognition that both pharmaceutical and medical providers in the market push their interests
aggressively and where these interests are well entrenched, it is harder to put in regulatory mechanisms.
There was considerable discussion around the quality of private and public sectors and many of the
speakers pointed out that evidence does not support the popular perception that the former provides
better quality than the latter. It was felt that in countries (like Thailand) that have higher investments in
health, the state is in a stronger position to regulate and define a clearer role for the private sector as
compared to countries where the state is either weak or practically non-existent in the financing and
delivery of health services.
Health Seeking Behaviour (Parallel Session B)
Chair: C.A.K. Yesudian
Rapporteur: Nupur Barua
Five studies from three countries, India, Indonesia and Thailand, and one drawing from six research
projects in the south and southeast Asian region were presented in this session.
15
The main issues that emerged during C.A.K. Yesudian’s presentation on health seeking behaviour
among the poor in urban India was the fact that the urban poor is a heterogeneous entity, and that there
are significant variations on the basis of income levels and the kind of occupation they are engaged in.
As a departure from evidence provided in previous studies, he pointed out that health seeking
behaviour is no longer driven by cultural perceptions of illness. He demonstrated, through two studies
in Mumbai and Bhopal in India, that pragmatic issues regarding access to, and location of, facilities, as
well as the perceived quality of services influenced the ways in which health care facilities are used.
Nupur Barua’s presentation examined the reasons for the overwhelming preference of the urban poor
for the individual untrained private practitioner in a slum in Delhi. Expenditure on use of government
facilities was found to be more expensive than these practitioners. The modalities of treatment inside
these clinics and competence constructions of different practitioners by the care seekers were discussed
in a context where the patient struggles to survive and the practitioner thrives by providing health
services in situations in which they are most needed.
Siwi Padmawati discussed the use of multiple health resources among the poor in urban areas in
Yogyakarta, Indonesia and the decrease in the use of public facilities. The increased use of self
treatment was emphasized and possible reasons for this development were discussed. The concept of
‘cocok’ or ‘suitable’ treatment, amongst the people suggests that the need to formulate and implement
public health reform needs to take local perceptions of quality of care into account.
Mubasysyir Hasanbasri’s presentation explored the reasons why health card holders in Indonesia use
the private sector for treatment and questioned whether the treatment offered by the private
practitioners ensured health protection for the public. He suggested ways in which the public sector
could be made more accessible and private providers more effective to ensure better health care to the
poor.
Angkhanaporn Sornngai presented the health problems among the re-settled elderly ‘boat-people’ in
Phitsanulok, Thailand and explored the economic problems that they faced because of this relocation.
16
In a discussion of the treatment seeking behaviour of this group, she suggested that a pro-elderly health
policy be framed with a holistic focus and with the collaboration of a multi-disciplinary health team.
Finally, Mark Nichter drew upon six of his studies across South and Southeast Asia to present the
increasing numbers and use of private practitioners and chemists in several rural areas and towns across
the region. The use of primary health centres for the chronically ill, utilization of private services for
TB treatment, self medication, and antibiotic use for sexually transmitted diseases were discussed. He
drew attention to the need to carefully scrutinize the definition of self–treatment in the context of
specific circumstances in which they are used, whether it signifies home remedies alone or whether it is
a continuum of earlier prescriptions from a health practitioner or self-prescription of over-the-counter
drugs. He emphasized that although providing good quality care is important, changing the perceptions
of the people - consumer education - is important and that both the demand and supply of health
services are equally crucial in the context of health service reform.
The discussion following the presentations focused on ways in which research could be used to impact
policy and how networks of researchers are important in order to raise visibility and translate research
into action.
Financing and health expenditures
Chair: Supasit Pannarunothai
Rapporteur: Rama Baru
Dr Agus Suryanto presented the Indonesian health care system and focused on the substantial variation
in Indonesia both in terms of demographics and in health system coverage in terms of manpower and
infrastructure for both government and private facilities. He pointed to the common dual (government
and private) practice among doctors and other health staff in Indonesia. He showed that the current
system does not eliminate inequity, measured in terms of health indicators such as under 5 mortality
rate and infant mortality rate, which are four times higher for the poorest quintile compared to the
richest. He pointed out that 46% of the population in Yogyakarta had no health insurance and that out-
17
of-pocket spending remained high. He said that the challenges for the health system were
underfunding, limited health insurance coverage, social and geographic inequalities and fragmentation,
and that there was weak stewardship of the entire system. He then outlined different scenarios with
different roles of the state and different mechanisms for financing the health system (insurance-based
versus social security). He recommended that the government strengthen its capacity to provide
stewardship, preventive care, social health insurance, and free or cheap services to poor and vulnerable
population groups. He ended by providing a set of more specific recommendations and stressed the
need for new financing mechanisms and provided the case of a quasi-government company that gives
health insurance to the poor in Yogyakarta province. Finally, he introduced the Health Care Quality
Council that is a recent body in charge of accreditation of medical institutions, among other quality-
related tasks.
Prof Supasit Pannarunothai completed the session by presenting comparative findings of the household
survey conducted under the project ‘Health System Reform and Ethics: Private Practitioners in Poor
Neighbourhoods in India, Indonesia and Thailand.’ The study was to compare health care seeking
behaviour and health care spending within poor households in the three countries. Households were
interviewed four times over a period of 12 months. The median income per capita of households in
Thailand was substantially higher and household size substantially smaller than in the other three
countries. Distinguishing between the poor and the very poor in each site, he noted that these two
groups were not very different in terms of income in the Bhubaneswar site, whereas there was more
substantial income variation in the other sites. The Poor in Delhi spent 4 times more money on alcohol
than the very poor. While there was a big difference in the proportion of the population that reported
illness across the four sites, there was not much difference between the two income groups within each
site, except for Thailand, where there were fluctuations that could be explained with the small number
of participants following depletion due to migration out of the area in the second to fourth rounds of
data collection. Health seeking patterns were also very different across the four sites. Interestingly, the
Delhi and Bhubaneswar sites showed markedly different patterns, where the former relying much more
on private clinics and the latter much more on government services. This was reflected in patterns of
spending per visit, which was markedly higher in Delhi that showed a pattern similar to the sites in
Indonesia and Thailand – in spite of universal coverage having been implemented in Thailand at the
18
time of data collection. The study was summarized through a number of observations: The very poor
had bigger household size, and income difference was highest in Thailand. The poor and the very poor
had similar morbidity patterns, but they fluctuated over the four waves of interviews. They used both
private and public services, but the very poor spent less per visit than the poor. They faced similar
incidence of payment difficulties, even in Thailand where the universal coverage policy is in place.
This difficulty decreased over the period of study. Professor Supasit concluded that private health
facilities are important for poor and very poor in urban neighbourhoods and that they should be
monitored for quality. The study raised a question as to whether care to the very poor is rationed. This
should be further explored. Access to care under the universal coverage policy may be revised to
provide better access to the poor in Thailand.
Regulation – scope and limitations?
Chair: Laksono Trisnantoro
Rapporteur: Kira Fortune Jensen and Jens Seeberg
Dr Ashok Kumar stated that Government of India (GOI) is keen to promote various Indian systems of
medicine including ayurveda, unani, siddha and homeopathy. GOI has a separate department called
AYUSH for this purpose. He said that only 59% of providers are allopathic practitioners. He detailed
the system of registration of medical practitioners based on the Indian medical council act of 1956.
Medical Council of India (MCI) acts as a statutory body. MCI takes care of medical institutions,
defines criteria and rules for medical colleges and recognizes medical schools. MCI also determines the
conduct of medical practitioners. If any medical practitioner is found to have carried out malpractice by
MCI, he/she is liable to one year imprisonment. MCI has state branches throughout India. Delhi
Medical Council was created by an act of the parliament in 1997 and formally established in 2001. The
Delhi state council preparers the code of ethics for practitioners in the state of Delhi, receives public
complaints against medical practitioners, administers punishment and provides protection to medical
practitioners against harassment; it is responsible for ensuring that no un-qualified person practices
modern medicine. The concept of ‘quack’, said Dr. Kumar, refers to a person who does not have
19
knowledge of a particular system of medicine but yet practices that system of medicine. The directorate
of health services and the state medical council is responsible for monitoring practice of modern
medicine by un-qualified practitioner. However there are many issues and problems in administration
of this system. For example, agencies act only on complaints and do not carry out regular surveillance
of their own. 163 complaints had been received by Delhi Medical Council but only 22 had been
prosecuted. According to an estimate by Indian Medical Association, about 30,000 non-qualified
practitioners are offering medical services in Delhi. Factors contributing to quackery include large
demand and inadequate health infrastructure; lack of coordination; poor monitoring and vigilance
mechanisms; poor enforcement of the law, long and tedious procedures; lack of awareness among
people; and self medication. Quackery can be decreased through improving health infrastructure;
improving public health outreach systems; on the basis of the Right to Information Act; based on the
National Rural Health Mission that aims to provide health care to all areas of the country; and by
strengthening health human resources with Public-Private partnership and capacity building.
Professor Soenarto Sastrowijoto stated that Indonesia has a ‘free market’ system of medical care. He
presented a desk study that intended to identify possible regulatory mechanisms for medical practice; to
examine existing rules and regulations; and to analyse ethical considerations with special reference to
the poor. He outlined the system of regulatory mechanisms in Indonesia and presented ethical cases
reported to the Medical Ethics Honorary Committee, including on advertising, mismanagement, and
sexual harassment etc. Cases from newspapers were categorised, including wrong or failed medical
interventions, illegal abortion and misdiagnosis. Only three cases had reached court. Professor Soenarto
discussed the details of these three cases and related them to the existing regulations as well as to
contextual factors such as shortage of health providers and the current financing mechanisms. He
pointed out that while the government health care system serves the poor, the government doctors
engage in private practice in the evenings and cater to the rich. He said that health sector reforms in
education, services, financing is required, that new acts and regulation are needed and that a model
should be developed urgently to address the issue of privilege regulation in transition for provincial and
district levels.
20
Professor Supasit Pannarunothai then presented the parallel study in Thailand. He pointed to the issue
of information asymmetry between health providers and service users and showed a dramatic increase
in complaints made to the Medical Council of Thailand following the economic crisis in 1997 and the
introduction of the universal coverage scheme in 2000. He reviewed the decisions made by the Council
across various types of complaints and suggested that bias could influence decision-making for some of
these. He proceeded to analyse claims made to the Medical Licensing Department and found that a
substantial number of cases were sent to court. However, in Phitsanulok, only very few court cases
were identified. These were presented. Prof. Supasit also illustrated media coverage through a number
of cases. He pointed to recent developments, such as community-based organisations, the setting up of
an accreditation system that increases emphasis on patient safety issues, and the introduction of a no-
fault compensation system. He also pointed out, that this no-fault compensation system so far has been
seriously underutilised and that it may be necessary to educate the judges involved in case evaluation to
achieve a desired change in assessing claims.
Dr Jenifer Lobo pointed to the existence in India of rampant malpractice at all levels of the health
system. She highlighted the lack of implementation and enforcement and asked whether this is due to
corruption or factors in the system that tend to enable malpractice. She raised the issue of government
doctors indulging in private practice as a main issue in that context and said that the uncovered health
needs of the large population also allowed private practitioners to practice without control and quality
measures being in place or being enforced. In the context of private hospitals she mentioned pressure
from patients and relatives, the mechanisms being put into place to protect health providers against the
consumer protection act, and the influence of private insurance companies who want to dictate
treatment on the basis of economical rather than medical grounds. She asked whether we can find other
solutions to these problems than regulation, which had not been particularly successful in the past.
DAY 2 (21 June 2007)
The proceedings of Day 1 of the workshop were summarized by Jens Seeberg. He pointed to four
cross-cutting themes, i.e. Health care seeking and patient rights; Rights, regulation and legislation;
Private health care delivery and quality of care; and Health financing. He pointed out some of the
21
important issues under each heading and said that the group work planned for the day would allow for
further discussions of these four themes.
Professional organisations and other NGOs
Chair: Jenifer Lobo
Rapporteurs: Siddarth Agarwal and Jens Seeberg
Dr Siddharth Agarwal in his presentation pointed out that in 2007, for the first time in the history of
mankind, the urban population would become larger than the rural. He mentioned the rapid growth of
urban slums and said that health care provision to this population was one of the growing challenges
for governments and civil society. He proceeded to show that in terms of basic health indicators, there
is vast disparity between urban average and urban poor populations, and that the urban poor are often
worse off than rural populations in spite of geographic proximity to health care services. He said that
public-private mix was required to address the needs or the urban poor and went on to offer a number
of different types of partnerships, involving NGOs (private non-profit), mobile clinics and, to a lesser
degree and perhaps with more difficulties involved, individual private (for profit) practitioners. Finally
he highlighted the need to map the needy urban populations, since, very often, official registration only
covers a fraction of the actual slum dwellings. He pointed to the fact that temporary and migrant
populations often are denied access to health care services and that partnerships need to be forged to
address their needs.
Ms. Widyawati Muhasan then introduced the private health sector seen from a nursing perspective. She
described the nursing situation in terms of the number of providers in the province of Yogyakarta and
pointed to issues of education, professional organization and legislation. Based on a qualitative study,
she found that nurses play a role in private health care and sometimes run their own private clinics
where they provide medical treatment, and she pointed to the related licensing problems. However,
patients felt they had easier access to these clinics than those run by medical doctors, and that they
received quicker and more affordable treatment. She pointed to issues of delegation of medical practice
by medical doctors to nurses and said there was a lack of supervision, monitoring and evaluation.
22
Mr. Marius Widjajarta discussed various pro-poor programmes that had been implemented in Indonesia
since the financial crisis in 1997. He went through the implementation process in detail and pointed to
various problems in terms of unclear distribution of responsibilities, insufficient transparency and weak
monitoring. He also mentioned that insurance cards were sold at the market and that often, they were
used by other people than the poor whom they were supposed to benefit. He provided a number of
examples of specific problems, such as costs not having been refunded, illegal administration of the
system, etc. He concluded by hoping that the current system would improve under tight community-
based monitoring.
After a short break, Dr. Somsak Lolekha talked about the “Role of Thai Medical Council in
Regulating Ethics of Private Practitioners”. He outlined the history, objectives and organization of the
Council and its links with educational institutions. He then presented the various activities of the
council and presented data concerning ethical claims made during 1973-2005. There had been a steep
increase in the number of claims around 1999. He mentioned the various types of sanctions that the
council could use when dealing with the claims. These included Dismissing the accusation; Warning;
Reprimand; Suspension of the license for a period 1-24 months; and Revocation of the license. He
outlined various strategies the doctor could use to prevent litigation, include good communication skills
and maintaining a good relationship with the patient. He concluded by introducing a tort reform, that
would imply the following elements: No criminal charge against doctors who have good intention to
treat patients; Cap damages; Encourage early offers for settlement; Use medical courts; Compensate
claims through a no-false administrative system; Implement pre-designated compensable events; and
Shift liability from individuals to organizations.
Jon Ungpakorn, in his presentation, focused on the role of civil society to push the medical
establishment and the government for reform. He emphasized the role of civil society and community-
based organizations and used the flourishing of activism around HIV/AIDS as a case in point. He
mentioned how civil society had played a constructive role in the formulation of the universal coverage
policy. He stressed that this could not only be based on a concept of health for the poor but had to be
23
based on a principle of health for all which would also include the poor. Mr Jon stressed the need to
include members of communities in medical institutions, from hospital boards to the medical council.
Using the case of AIDS, he said that access to antiretroviral treatment had been included under this
policy as a result of community-based pressure. He said that while many different groups had joined
hands to form a strong community around AIDS, this had paved the way for other groups and networks
to follow and pursue issues related to other diseases. He drew attention to the a range of issues where
civil society had a crucial role to play in Thailand, such as community health education and care
services; policy advocacy concerning access to prevention, care and treatment; support for malpractice
and negative outcome compensation; access to essential drugs; and community health funds. He also
called attention to the global drainage on the health system, where middle class patients from western
countries go to countries such as India and Thailand for treatment, because it is cheaper than being
treated in their own country. Such global movements drain the Thai government system for resources.
Anil Jacob Purty set out to define partnership and mentioned issues of capacity of the private partner,
advocacy, accreditation and regulation by the Government as being important for the success of such
partnerships. Using experiences from the Pondicherry Institute of Medical Sciences, he highlighted
activities such as teaching and training, primary health care, community-based research, health
education and school health programmes, liaison with Government departments for National Health
Programmes (such as immunization programmes and tuberculosis control), and co-ordination with
national and international NGOs for public health practice. Dr. Purty then provided morbidity data to
illustrate the success of the approach adopted. He concluded his presentation by mentioning some of
the challenges for public-private partnerships, such as cost containment, effective use of private
resources, logical diversion of public resources, synergy to reduce duplication and resource
mobilization.
Group Work 1: Comparative Perspectives
Jens Seeberg introduced a format for the afternoon’s group work. Four groups were established and
asked to work with one theme each. All three countries (India, Indonesia and Thailand) would be
represented in each group. The groups would address three questions under their respective themes,
24
both for each country individually and in a comparative perspective. The outcome of the group work
was to provide input for the planned country-specific group work that would take place on Day 3. The
group work formats with the result from each group have been inserted as Annex 3 of this report.
DAY 3 (22 June 2007)
The meeting had invited Mark Nichter to share his observations. Prof. Nichter called attention to the
dual chronic state of ill-health and poverty that sets the agenda for coping and survival strategies for the
urban poor. He pointed to questions such as ‘why would both sides bother to work together in a public-
private partnership?’ What could be motivating factors – or convertible forms of capital – besides
money? He called attention to the notion of health citizenship as part of the wider concept of
biosociality, i.e. mobilizing people in networks around diseases such as HIV/AIDS and diabetes. He
mentioned the need to gradually and incrementally enhance the credibility of the health care system. He
then shifted focus and said that there was a need to take the aging of populations and the increase of
chronic disease much more into account in policy discussions. He called for policy makers to speak up
and raise issues for research and tell researchers in which form they can use research. He suggested
using stakeholder analysis as a way of translating results into policy. He then mentioned a number of
research issues that he felt needed more attention, including research on the role of the pharmaceutical
industry; applied research on use of modern technologies to give practitioners swift access to
appropriate information and CME; and analysis of the impact of rhetoric and language in general on the
way we understand these problems. He posed the challenge to the meeting to move beyond cases and
address the issue of ‘so what’ – where to go after the meeting?
Government perspectives
Chair: Prof. Soenarto
Rapporteur: Jens Seeberg
Dr. Deoki Nandan started his presentation by stating the dominant role of the private health care sector
in India and compared it with the government sector in terms of quality, access and costs for the
25
payment, mentioning that existence of corruption in the government sector often required patients to
pay bribes to doctors to receive appropriate treatment. He said that Indian Medical Association
systematically had resisted regulations and that Medical Council of India had taken very little action
against doctors violating the code of ethics. He noted the change in the private health sector from
individual clinics and small nursing homes to private hospitals and hospital chains. He noted that the
quality of private clinics and nursing homes varied dramatically. Key issues with unsatisfactory quality
included disposal of medical waste, lack of labour rooms, dirty beds, poor lighting, unsatisfactory
recording procedures, and not displaying license prominently. He said that the sector is poorly
regulated and that quality assurance mechanisms are not in place, but that regulation has been passed
recently in some areas, including for drugs, medical practice and health facilities. He said that it was
necessary to impose greater social accountability on private providers, to make a certain proportion of
private services available to the poor, to reconsider geographical distribution of health services, and to
explore the potential of franchising. He then introduced elements of the National Rural Health Mission
(NRHM) in terms of community involvement, financing, monitoring of standards of care, improved
capacity for management, and innovation in human resource management. Recognizing the dominant
role of the private sector, he said that there was a need to reform regulation and make processes
transparent and people involved accountable. Dr. Nandan outlined the existing scenario for public-
private-people-partnerships under the NRHM that included guidelines for PPP in national health
programmes, social franchising, contractual appointments, contracting services such as diet and
catering, laundry, security and IEC programmes. He said that Government of India has constituted a
Technical Advisory Group, consisting of government officials, development partners and other
stakeholders to conceptualize strategies under this heading. An Urban Health Task Force has been
established as an offshoot of the NRHM, which recommended collaboration with NGOs, situational
analysis and mapping of slums, improved management of urban health centres, use of outreach clinics
in urban slums, and emphasis on community-based organizations.
At the workshop, it was announced that the Government of India was about to launch its Urban Health
Mission. Dr. Siddharth Agarwal provided information on this topic, as follows:
26
India has been urbanizing rapidly in recent decades. The urban population of India grew by 68 million
during the decade 1991-2001 which translates to a decadal growth rate of 31.2 per cent. This is nearly
double the rural population growth rate. Along with urban growth there is a rapid urbanization of
poverty. 100 million persons or one-third of the urban population of India resides in slum or slum like
conditions. The urban poor are the fastest growing sections of the population and the UN-HABITAT
estimates that the urban poor will reach 200 million by 2020.
The urban slum communities suffer from poor health outcomes, which do not get reflected in the
commonly available data sources that show rural-urban comparisons. Disaggregating health indicators
within urban areas by Standard of Living Index (SLI) reveals some startling findings. Among urban
poor households child mortality rate (U5MR) (101.3) is nearly thrice, severe under nutrition is twice
(23%) and complete immunization is almost half (43%) than corresponding figures among urban high
income groups. Likewise the reach and utilization of essential preventive health services is
overwhelmingly low with 4% using birth spacing method and only 3 out of every 10 children affected
with diarrhoea receiving ORS.
The Government of India has recognized the growing urban poverty and their poor health. Urban health
received special mention in National Population Policy 2000, National Health Policy 2002, 10th Five
Year Plan, and the second phase of the Reproductive and Child Health Program (RCH II) and the very
recent National Rural Health Mission (NRHM) (2005-2012).
In June 2005, the Government of India constituted a Task Force to advise the NRHM on strategies for
urban health care. After a series of deliberations between August and October 2006, the Task Force has
recommended that there should be a National Urban Health Mission on the model of NRHM. In terms
of urban health care strategies, the Task Force recommends a) an Urban Health Centre (UHCs) catering
to every 50,000 population (which is anticipated to include about 25,000 urban poor); b) a Second Tier
Health Facility for 250,000 population covering 5 UHCs and forming a ‘Health Zone’; c) regular
outreach services in the slums by ANMs to ensure the provision of preventive, promotive and curative
services; d) community level activities primarily by slum based Link Volunteers (LVs) and Women’s
groups with coordination support from NGOs; e) an enhanced role of urban local bodies, private sector,
27
NGOs; and f) improved coordination of the health department with other relevant departments
including Ministry of Urban Housing and Poverty Alleviation, ICDS in improving the health of urban
slum communities. The package of services recommended for First Tier Level and through outreach
services includes ANC, PNC, child health services, family planning services, treatment of
communicable diseases, counselling, and laboratory services. At the second tier maternity services,
neonatal, paediatric services, reproductive health and other general hospital services have been
recommended. The Government accepting the recommendations of this Task Force, in June 2007
announced the decision to soon launch the National Urban Health Mission.
Dr Agus Purwadianto, on behalf of the Government of Indonesia, in his presentation gave an
introduction to the Indonesian health care system in terms of organization and structure. He said that
current priorities for the system included maternal and child health; poor people health services;
empowering health personnel; communicable diseases and malnutrition, health crises due to disasters;
and health services for remote areas and islands. Using key health indicators, he highlighted some of
the achievements in the past. Dr Agus then shifted attention to the legal framework and discussed the
complaints to the Medical Ethics Honorary Board in terms of type of complainant, medical specialty
involved and type of complaint. He continued by looking at cases reported to the police and related
these to the issuance of the Medical Practice Act. He raised the issue of professionalism and said that
there was a public perception that medicine failed to regulate itself in a way that can guarantee
competence, and that it put its own interest above that of patients and the public. Also, he said that in
the past, the medical fraternity protected incompetent and unethical colleagues in the name of
collegiality. He introduced a series of steps that were taken since 2003 to address this issue, including
reform of the bodies that were responsible for addressing these problems on a daily basis. Dr Agus
highlighted the concept of professionalism as a key to address such problems and said that
professionalism had to be based on a principle of primacy of patient welfare; a principle of patient
autonomy; and a principle of social justice. He related this discussion to the ethico-legal framework in
Indonesia and to the role of bureaucracy as a formative force in the system, which could work both in
positive and negative directions. He said that transparent administration and management were keys to
improving the system and used the dispensing and sale of drugs as a case in point. He concluded that
in Indonesian health regulation, the concept of professionalism was being considered. Health reform
28
29
policy to support the poor and least advantaged people could be a panacea for their dissatisfaction of
“out of pocket” health care system while going to a managed care system using the social security act
and health insurance regulation, beginning with the Minimum Service Standard.
Group Work 2: Country-specific Perspectives
Chair: Yati Soenarto
The purpose of the final group work was to develop key recommendations for policy makers for each
country on the basis of a) the research input that had been fed into the workshop, and b) the group work
about comparative perspectives that had been completed on the previous day. Three groups were
formed, one for each country, and the assignment, that was presented by Jens Seeberg, was to address
all four themes that had been discussed by individual groups on the previous day. The results are
provided in the formats below.
INDIA
THEME 1: Health Care Seeking and Patient Rights
Prioritize the three main problems/needs related to health care seeking and patient rights.
1. Access barriers in terms of a) physical, social access and quality of public health facilities; and b) affordability of the
public sector.
2. Inadequate health infrastructure and manpower vis-à-vis established norms
3. The poor often use private sector providers with questionable qualifications; or are forced to visit expensive private
providers
4. High proportion of out-of-pocket expenditures for health and lack of health insurance for the poor
Primary recommendation for policy
• Policies should focus on demand, strengthen supplies and quality of services and establish linkages between available
public and private health providers.
o Motivation, sensitization, capacity building (about social skills) and recognition of better performers should be
pursued
o Regular outreach services for vulnerable slum clusters should be ensured
o Linkages with available health providers through slum based ‘link volunteers’ should be developed; community-
based health groups should be engaged to enhance utilization of health posts
o Education of urban poor communities should be strengthened. This should include knowledge about a) healthy
behaviour; b) appropriate services; c) rights to health care
30
Secondary recommendations
1. Capacity of informal sector should be built and practitioners linked to the public health system and/or organized
2. Partnerships with socially responsible private providers should be developed
THEME 2: Rights, Regulation and Legislation
Prioritize the three main problems/needs related to rights, regulation and legislation in terms of impact.
1. Poor understanding among urban poor of their rights vis-à-vis the public sector and provisions available to them; weak
negotiating power
2. Migration, domicile challenges and social exclusion that impair the ability to access rights/health services/entitlements
3. Weak regulation for the informal private health sector
4. No separate legislation/regulation for private sector
Primary recommendation for policy
• There is a need to design and implement an urban health care service delivery system, keeping in mind city-
specific situations
Secondary recommendations
1. To map all listed as well as unlisted urban poor clusters including pavement dwellers, brick, lime-kiln workers,
construction workers on city map for urban health planning, implementation and ensuring right to health services
2. To enhance negotiating capacity of urban poor communities to improve ability to avail entitlements
3. To develop regulation of private informal sector to ensure that they play a meaningful role
4. To develop regulations for need-responsive public-private mix and modify them based on initial experience
31
THEME 3: Private health care delivery and quality of care
Prioritize the three main problems/needs related to private health care delivery and quality of care.
1. Lack of standards of quality and fee structure in a context of demand, utilisation and growth of less qualified practitioners
2. Lack of continued upgrading of knowledge and skills of all private providers
3. Inadequate linkages between private and public health sectors
Primary recommendation for policy
• Legislation to ensure optimal standards of private providers in the informal as well as the formal sector should be framed
and energetically implemented.
Secondary recommendations
1. To establish a system of periodic CME for both formally qualified practitioners and informal private practitioners,
involving available agencies and professional bodies
2. To promote and ensure quality of care
THEME 4: Health Financing
Prioritize the three main problems/needs related to health financing
1. High out-of-pocket expenditure owing to high cost of health care
2. Low investment and poor distribution of financing for human resources and infrastructure
3. Imbalance of financing on preventive and Primary care/OPD vs curative/hospital care
4. Lack of health insurance systems for the poor
32
Primary recommendation for policy
• Increase rational (i.e. balanced with respect to preventive, primary and hospital care) investment in public health services
with a focus on the urban poor
Secondary recommendations
1. Establish health insurance for the poor, based on learning from small-scale community health financing initiatives in
different states
INDONESIA
THEME 1: Health Care Seeking and Patient Rights
Prioritize the three main problems/needs related to health care seeking and patient rights.
1. Self-medication (70%) and harmful medication
2. Patients’ demand leading to irrational medical treatment
3. Imbalance in accessibility, affordability, and distribution of health services
Primary recommendation for policy
• Strengthen proper information and education (both for patients/consumers and providers)
o Socialization concerning and enforcement of regulations on patients’ and consumers’ right
o IEC through CBOs
Secondary recommendations
• Conduct research related to financial and cultural barriers to formal health care system
33
THEME 2: Health care seeking and patient rights in terms of impact
Prioritize the three main problems/needs related to health care seeking and patient rights in terms of impact.
1. Growing market of traditional and lay medication (health resources)
2. Black Market
3. Increasing burden of illness due to untreated and chronic diseases
Primary recommendation for policy
• Enforcement of related regulations
• Quality improvement of public primary health care, thereby increasing the credibility of the public health system
Secondary recommendations
1. Involving district health office in monitoring and controlling
2. Ethics and legal awareness of various parties (universities, MoH, professional organizations)
THEME 3: Private health care delivery and quality of care
Prioritize the three main problems/needs related to private health care delivery and quality of care.
1. Private providers are marginalized or neglected by the public health agencies
2. Over/irrational medication
3. Cost variation
Primary recommendation for policy
34
• Optimizing the use of private health care in accessing the poor
• Integrating private providers to act as agents for public health
• Purchase of private health service for the poor by the government (outsourcing the service for the poor through
private sectors)
Secondary recommendations
• Purchase of private health service for the poor by the government (outsourcing the service for the poor through private
sectors)
THEME 4: Health Financing
Prioritize the three main problems/needs related to health financing.
• Although there had been an increase of public finance in health, in fact private finance still dominates the health sector
• The main problem: insufficient government budget and low willingness to improve the quality of public health care.
Impact
• Low credibility of primary health care service (out-patient)
• No equitable distribution of in-patient care resources
• In terms of in-patient care, the urban poor are better off than rural and remote poor. For out patient care they have an
alternative to public service in the “unregulated” private sector
• For rural poor and remote areas: In-patient is not as good as urban poor (geographical in-equity). Less hospitals and
medical doctors.
35
Primary recommendation for policy
Tapping more resources for health
• Increasing public budget: central, provincial and district governments
• Expanding private finance through insurance scheme, not fee-for-service
Secondary recommendations
• Improving the quality of primary care (requires more research)
• Reducing the gap of geographic inequity: “more suitable medical doctor/specialist education for remote areas” and push
medical doctors to work in remote area (operational research)
• Developing medical care network in outer provinces
THAILAND
THEME 1: Health Care Seeking and Patient Rights
Prioritize the three main problems/needs related to health care seeking and patient rights.
Consumer:
• Accessibility problems in terms of physical and social environments, affordability problem related to travel expenses,
etc.
• Lack of knowledge of rights for service.
• Unrealistic expectation; false need; low trust on services provided under the universal coverage scheme.
Provider:
36
• Health care service not suitable in terms of consumer needs (convenient timings, etc.)
• No strict regulation of access to services.
Primary recommendation for policy
Empowerment of both consumer and provider.
Consumer:
• Provide knowledge about the rights to service and regulation.
• Encourage community participation in health care system.
Provider:
• Develop leadership skills among health providers.
Secondary recommendations
Further research is recommended to answer these research questions:
• How to understand the lifestyle of the urban poor and how to improve the quality of care to fit their needs?
• How to raise the trustworthiness on the public system from the patient and provider perspectives?
THEME 2: Health care seeking and patient rights in terms of impact
Prioritize the three main problems/needs related to health care seeking and patient rights in terms of impact.
1. Most of health workers in private sector are not MDs, whereas in public sector there are more MDs.
2. There are limitations in the ability to reduce inequity problems; gender equity.
3. The law to control health premises is available, but it addresses only the private sector.
37
Primary recommendation for policy
Enhancing health personnel to provide a holistic health service; as well as increasing the standards of hospitals according to
Hospital Accreditation or ISO 9000.
Secondary recommendations
• Explore the weaknesses and strengths of the private health systems.
• Research and development on implementation and evaluation of health service quality.
THEME 3: Private health care delivery and quality of care
Prioritize the three main problems/needs related to private health care delivery and quality of care.
1. Inaccessibility of the private health sector for the poor.
2. Lack of monitoring and evaluation system on private health sector.
3. Over-treatment and expensive treatment.
Primary recommendation for policy
• Core package of universal coverage scheme should be designed to cover private health care and extended to community
health.
• Strengthening the monitoring and evaluation of private health sector using internal and external assessors with
coordination of multiple agencies and based on clearly defined quality standards.
• Payment to hospital on DRG basis should be integrated into private hospitals.
38
39
Secondary recommendations
• Feasibility study of UC core package for private health care.
• Study on effectiveness of private health care providers.
• Study on cost-effectiveness of private health care delivery and quality of health care.
THEME 4: Health Financing
Prioritize the three main problems/needs related to health financing.
1. Inequities in health service delivery between income groups (intra-urban and rural-urban differentials).
2. Risk for catastrophic illness (and out-of-pocket payment) especially in private sector.
3. Lack of resources for preventive care.
Primary recommendation for policy
• Inequity of health service delivery between income groups (intra-urban, rural-urban) should be reduced.
• There should be adequate source of financing for provision of preventive care by both public and private sectors.
• Source of fund for the compensation of adverse events in private sector should be studied.
Secondary recommendations
• The purchasing role to enhance equity and a strategy to increase sources of financing should be explored.
• Methods for controlling quality of health care (i.e. regulations, monitoring systems etc.) in relation to financing methods
should be arranged.
• Methods for encouraging preventive care through payment systems should be studied.
CLOSING SESSION
Chair: Prof. Supasit Pannarunothai.
Rapporteur: Nupur Barua
The concluding session brought to the table final comments from participants from all the countries.
Jens Seeberg began the session by outlining the main themes that had emerged during the deliberations
in the past three days under the following heads: patient rights, self-medication, inequity in access to
health services, out-of-pocket expenditure on health and issues around insurance for the poor. The
provision of health services was the central issue in all the three countries – India, Indonesia and
Thailand.
In the discussions that followed, it was felt that while the workshop offered a very useful forum to
discuss the complexities of the problems regarding the urban poor in all the countries, there had not
been enough time to discuss the recommendations and lessons learnt from each country in detail. It was
suggested therefore that all the recommendations be placed on the project website to enable access by
all countries. The possibility of framing advocacy materials for each country was deliberated.
Supasit Pannarunothai from Thailand facilitated a discussion on ‘what next?’ - at both the network-
level and country-level. Soenarto Sastrowijoto from Indonesia announced that they would hold a
meeting of representatives from the government, the NGO sector, and the university to discuss and
analyze inputs from India and Thailand and to develop a plan of action of reform of various regulations
at the district level in Yogyakarta. They would present the same to the government to stimulate action
at the regional level. C. S. Pandav from India felt that this workshop had provided an opportunity to
bring together people from various levels – from the ministry, the research community, the political
arena, and from medical colleges – to discuss and share experiences of the complexities of health
provision for the urban poor in all three countries. He informed that an India Group would be formed,
along with the National Institute of Family Welfare, to discuss the current research findings and policy
implications of the same vis-à-vis the recently announced Urban Health Mission by the Govt. of India.
40
The group would also draw lessons from the Indonesian and Thai experiences to see ‘what works’.
Furthermore, he emphasized the need to go beyond the local level in each centre to frame a regional
agenda keeping in mind common areas of interest within the overall focus on urban health and hoped
that Danida would be associated with subsequent efforts in the region. Prof. Supasit carried the
discussion further by emphasizing the need to develop action plans at provincial, country and regional
levels and said that it was important to focus on particular examples as a basis for policy development
and on ways to do advocacy for a more equitable and rights-based health system.
C.A.K. Yesudian from India emphasized the timeliness of this meeting when the Govt. of India, for the
first time, was focusing on urban health as a priority area and that this exercise should feed into the
proposed Urban Health Mission. The learning about the less-qualified practitioners could be of
particular importance in this context. At the regional level, he asserted that this group could contribute
to larger studies on public-private mix and health financing and suggested that more countries from the
region, Sri Lanka, Bangladesh and Malaysia, could be added to form an Asian Health Observatory in
the lines of the European Health Observatory. This would not only expand the area of study but could
also influence policy.
Dr. Deoki Nandan, as a representative head of the National Institute of Health and Family Welfare
emphasized that his organization functions as the think tank for the MoHFW in India and offers
opportunities for capacity building, research and advocacy on urban health management and health
financing. He emphasized that beneficial collaborations across various levels could be forged with his
organization to focus on various issues regarding urban health development in the country. Dr. Ashok
Kumar from the Govt. of India conveyed that the Director General of Health Services was very pleased
that this inter-country effort was taking place. He said that he would carry the experience back and
would be interested to facilitate a possible development of a network, so that the technical competence
of this group could be used to invigorate a wider movement in the region to eventually translate the
research into action.
A representative from the City Health Office in Yogyakarta said that lessons learnt during the
workshop could be implemented at the district level and collaborations with the university and between
41
NGOs and the government could provide research grounding for improving the quality of life in the
city, especially with regard to primary health care provision. Laksono Trisnantoro from Indonesia
stressed that an international perspective could be gathered through collaborative ventures of this sort
and emphasized the importance of holding meetings of this kind. He sought information on post-project
avenues for holding subsequent meetings. He particularly drew attention to the need to focus on
regulation and financing for the poor.
Jens Seeberg said that he hoped that this meeting would establish the much-needed platform for follow-
up stakeholder meetings, involving researchers, NGOs, and civil society organizations. The main
problems that needed attention are issues regarding access, wrong medication (over-use or under-use),
equity, financial security, and the functioning of the private sector. In addition, he stressed the need to
look more closely at the pharmaceutical industry and the impact that the lack of regulation of the
industry has on the urban poor residing in slum areas through the private practitioners. Issues
concerning private insurance and the way it influences health service delivery in the private sector to
the poor need to be examined. He asked what could be done with the research and pointed to the need
to go beyond the case studies. The potential influence of WHO in taking the agenda further beyond the
local level was emphasized.
Rama Baru pointed out the need to go beyond the policy makers and to take into consideration the
people’s health movements which play an important role in policy advocacy. She suggested that a
summary of the present study be given to such groups and highlighted the importance of publishing the
proceedings in reputed journals like the National Medical Journal of India and The Economic and
Political Weekly. Media reporting of such a meeting would influence civil society.
Yati Soenarto shared experiences about the decentralized management in the Indonesian initiative in
control of diarrhea and emphasized the need to influence the government to translate research results
into policy. The Indonesian team highlighted the importance of budget allocations, transparency of
public health administration and surveillance of data in public health programmes for the poor and
drew attention to problems that accrue from bad regulations.
42
Further discussion centered on the importance of development of research of this kind in the region and
the possibility of further collaborations of this kind. The need for academic publications and
collaborations with academic organizations for such research was highlighted.
Finally, Jens Seeberg summarized the main issues that emerged from each country under four cross-
cutting themes:
1. Health care sector and patient rights: Harmful medication consumption, the need to focus on
the real problems, for instance urbanization and migration into cities, the role of health
citizenship and the need to rethink health care delivery to people who are on the move;
2. Rights, regulation and legislations: Implementation and enforcement, mechanisms for conflict
resolution, enforcement of disciplinary measures that have been put into place as one
mechanism, strengthening of positive motivations as another important mechanism, and issues
regarding how to make profit and still provide good quality services in the private sector;
3. Quality of services: Strengthening of government services in urban areas, the need to include
the middle class to ensure that service delivery mechanisms go beyond providing poor public
health for the poor, incorporation of less- qualified private practitioners, establishment of
dialogue in a scenario where the current move of raids in Delhi have proven not to be very
effective, and finding news ways to access continued health education;
4. Health Financing: The Universal Coverage Scheme held suggestions for India along the same
lines, but there were also important lessons to be learnt from the Thailand experience in pursuit
of equitable funding mechanisms.
He closed the session by reiterating that this forum, the ongoing research, and inputs from the
participants could be used by the group during the proposed national-level workshops in each country.
He suggested that policy briefs be prepared by each country for these meetings to facilitate the process
of taking research to action. Furthermore, he said that this forum could also facilitate the formation of
networks and collaborative groups in the region.
43
ANNEX 1: Programme
20 JUNE: RESEARCH
08.00-08.30 Registration
08.30-09.30: Inaugural session
Introduction by Supasit Pannarunothai
Welcome address by Mondhon Sanguansermsri, President, Naresuan University
Opening remarks by Jens Seeberg, University of Aarhus
Inaugural Address by Special Guest of Honour Samlee Plianbangchang, Regional
Director, WHO (SEARO)
09.30-10.00: Coffee (registration cont.)
10.00-12.00: Health Sector Reform and Public Private Mix? Keynote presentations and panel
discussion (Chair: Prof. Supasit)
Chandrakant S. Pandav (India): Health Sector Reform in India
Laksono Trisnantoro (Indonesia): Health Sector Reform in Indonesia: A scenario
planning analysis in controlling private sector
Pongpisut Jongudomsuk (Thailand): Health Sector Reform: the case of Thailand
Firdosi Mehta (Indonesia): Successes, scope and limitations of public-private
partnerships in Asia. Experiences from TB control and beyond
Reidar Lie (Norway): Private health care, health and human rights
12.00-13.00: Lunch
13.00-15.30: Private health sector – Parallel sessions
A. Quality of care and dynamics of the health system (Chair: Dr. Pongpisut)
Jens Seeberg (Denmark): Market dynamics and private health care delivery.
The case of Bhubaneswar, India
Rama Baru (India): Structure and Quality of Private Health Services in India
Roy Tjiong (Indonesia): A Dynamic of (Private) Health Sector and Quality
of Care
Choirul Anwar (Indonesia): Health Service Policy for Private Sector in the
City of Jogjakarta
Aumnoay Pirunsarn (Thailand): Private Health Provider Behaviour and
Clinical Communication Patterns: Cases from Phitsanulok, Thailand
B. Health Seeking Behaviour (Chair: Dr. C.A.K. Yesudian)
C.A.K Yesudian (India): Health seeking behaviour of urban poor in India
Nupur Barua (India): The discreet charm of the private practitioner: Access,
utilization and quality of health care in a slum in Delhi
44
Siwi Padmawati (Indonesia): Searching for Suitable Cure: Understanding
Medical Pluralism in Urban Poor Neighborhoods in Jogjakarta, Indonesia
Mubasysyir Hasanbasri (Indonesia): The use of private provider among
health card holders in Indonesia
Angkhanaporn Sornngai (Thailand): Health Problems and Needs among
Low-Income Elderly in Phitsanulok, Thailand
Mark Nichter (USA): Lessons from studies of health care seeking in
pluralistic health care arenas of South and Southeast Asia
15.30-16.00: Coffee Break
16.00-16.50: Financing and health expenditures (Chair: Prof. Supasit)
Bondan Suryanto (Indonesia): Financing Health Sector: Public and Private Mix
in Jogjakarta
Supasit Pannarunothai (Thailand): Health seeking and spending of people in four
urban poor neighbourhoods in India, Indonesia and Thailand
16.50-17.00 Break
17.00–18.30: Regulation – scope and limitations? (Chair: Dr. Tawesak)
Ashok Kumar (India): Regulation of Medical Practitioners in India
Soenarto Sastrowijoto (Indonesia): Regulating Health Professions: The Dilemma
in Medical and Health Practices for the Poor in Indonesia
Supasit Pannarunothai (Thailand): Systems of Ensuring Ethics and Quality in the
Thai Private Healthcare
Jenifer Lobo (India): Medical Malpractice in India: Is Regulation the Only
Solution?
19.30: Workshop Dinner
21 JUNE: COMPARATIVE PERSPECTIVES
09.00-09.30: Summary of Day 1
09.30-10.40: Professional organisations and other NGOs (Chair: Dr. Lobo)
• Widyawati Muhasan (Indonesia): Independent Private Nursing Practice in
Indonesia, is it essential? A Case Study
• Marius Widjajarta (Indonesia): Poor Community Health Monitoring In
Indonesia Since Monetary Crisis
• Siddarth Agarwal (India): Public Private Partnerships for Improving Health
of the Urban Poor: Lessons and Best Practices from India
10.40-11.00 Coffee Break
45
11.00-12.00 Professional organisations and other NGOs (Cont.)
• Somsak Lolekha (Thailand): Role of Medical Council in Regulating Ethics of
Private Practitioners
• Jon Ungpakorn (Thailand): Roles of NGOs for Health of the Poor
• Anil Jacob Purty (India): Public-Private Partnership for Health Care. Our
experience and the road ahead
12.00-13.00 Lunch
13.00-15.30 Afternoon: Group Work – Cross-country perspectives (South and Southeast Asia)
(Chairs: Gr.1: C.A.K. Yesudian, Gr.2: Deoki Nandan, Gr. 3: Ashok Kumar, Gr.4: Rama Baru)
15.30-16.00: Coffee Break
16.00-17.00 Plenary presentation of group work results (Dr. C. S. Pandav)
22 JUNE: COUNTRY PERSPECTIVES
09.00-10.20
• Government perspectives (Chair: Prof. Soenarto)
o Deoki Nandan and Siddharth Agarwal (India): Private Sector in the context of
the National Rural Health Mission and Urban Health Task Force
Recommendations
o Agus Purwadianto(Indonesia): New Regulation on Health Services in Indonesia
10.20-10.40 Coffee Break
10.40-12.30 Group Work – Country-specific Policy Perspectives
12.30-13.30 Lunch
13.30-15.00 Plenary presentation of group work results (Chair: Dr Yati Soenarto)
15.00-15.30 Coffee Break
15.30-17.00 Report with recommendations (Chair: Prof. Laksono)
Closing Session
46
47
SATELITE MEETING
22 JUNE
20.00-22.30 Disaster management in the light of the Yogyakarta 2006 earthquake and the 2004
tsunami
o Retna Siwi Padmawati (Indonesia): The 27May06 Earthquake in Yogyakarta
Province
o Widyawati Muhasan (Indnesia): Community Empowerment by Mobile
Rehabilitation
o Jain Veeraphing (Thailand): Mudslide and Community Help in the North of
Thailand
o Vorasith Sornsrivichai (Thailand): Man-made Disaster: Violence in the Deep
South of Thailand
ANNEX 2: List of participants
No Name Title Affiliation Country e-mail add.
1 Siddharth Agarwal Executive
Director Urban Health Resource Centre, New Delhi India siddharth@uhrc.in
2 Choirul Anwar Dr. Distrct Health Office(Yogyakarta) Indonesia choirulanwr_jogja@yahoo.co.id
3 Rama Baru Associate
Professor Centre of Social Medicine and Community
Health
Jawaharlal Nehru University, New Delhi
India rbaru2002@yahoo.co.uk
4 Nupur Barua Co-PI HSRE Project, ICCIDD/AIIMS and
University of Aarhus India nupur_barua@yahoo.com
5 Sanjay Kumar Gupta Assistant
Professor Pondicherry Institute of Medical Sciences India s_kgupta2000@yahoo.com
6 Mubasysyir Hasanbasri Dr. Gadjah Mada University Indonesia mhasanbasri@ugm.ac.id
7 Yulita Hendrartini Gadjah Mada Dentistry School Indonesia
8 Dounghathai Janchua Naresuan University Thailand d_janchua@yahoo.com
9 Kira Fortune Jensen Coordinator Danish Network for Internation Health
Research Denmark
10 Pongpisut Jongudomsuk Dr. HSRI Thailand pongpisut@hsri.or.th
11 Orathai Kheawcharoen Naresuan University Thailand Orathail2000@yahoo.com
12 Ashok Kumar Director Central Bureau of Health Information, Govt.
of India India dircbhi@nb.nic.in
13 Reidar Lie Professor NIH Norway reidar.lie@gmail.com
14 Supon Limwattananon Associate
Professor KKU Thailand supon@kku.ac.th
15 Jenifer Lobo Dr. Ex-AIIMS and Holy Family Hospital, New
Delhi India
16 Somsak Lolekha Professor TMC Thailand slolekha322@yahoo.com
17 Firdosi Mehta Dr. World Health Organisation Indonesia MehtaF@who.or.id
18 Andreasta Meliala Gadjah Mada Medical School. Indonesia
19 Widyawati Muhasim Gadjah Mada Dentistry School Indonesia Widyawati_ugm@yahoo.com
48
20 Deoki Nandan Director National Institute of Health and Family
Welfare, New Delhi India dnandan51@yahoo.com
21 Mark Nichter Professor University of Arizona USA mnichter@u.arizona.edu
22 Sirinard Nipaporn Naresuan University Thailand Sirinard@nu.ac.th
23 Retna Siwi Padmawati Gadjah Mada University Indonesia raniabi2003@yahoo.com
24 Chandrakant S. Pandav Head Centre for Community Medicine, All India
Institute of Medical Sciences, New Delhi India cpandav@iqplusin.org
25 Supasit Pannarunothai Professor Naresuan University Thailand supasitp@nu.ac.th
26 Bupawan
phuaphanprasert Naresuan University Thailand bupawang@gmail.com
27 Aumnoay Pirunsarn Naresuan University Thailand imtomkrub@yahoo.com
28 Samlee Plianbangchang Regional
Director World Health Organisation India
29 Anil Jacob Purty Associate
Professor Pondicherry Institute of Medical Sciences India purtyanil@sify.com
30 Agus Purwadianto Dr. Ministry of Health Indonesia aguspurwadianto@yahoo.com,
hukumresponsifudepkes@yahoo.
co.id
31 Petcharee Reungon Naresuan University Thailand peecharee313@yahoo.com
32 Sakchai Naresuan University Thailand sakchaichai@hotmail.com
33 Soenarto Sastrowijoto Professor Gadjah Mada University Indonesia bioetika_2007@yahoo.com
34 Jens Seeberg Associate
Professor University of Aarhus Denmark jseeberg@hum.au.dk
35 Yati Soenarto Dr. Gadjah Mada University Indonesia yatisoenarto@yahoo.com
36 Angkhanaporn Sornngai Dr. Sirinthon Collage Phitsanulok Thailand angkhanaporn@yahoo.com
37 Vorasith Sornsriwichai Dr. PSU Thailand vorasith@msn.com
38 Deni Sunjaya Padjadjaran University Medical School Indonesia dk_sunjaya@yahoo.co.id
39 Bondan A. Suryanto Dr. Provincial Health Office(Yogyakarta) Indonesia bonaqusur@yahoo.com
40 Panadda
Taechasubamorm Naresuan University Thailand gsu1994@yahoo.com
41 Roy Tjiong Dr. Hellen Keller Indonesia Indonesia rtjiong@hki-indonesia.org
49
42 Laksono Trinantoro Dr. Gadjah Mada University Indonesia Ltisnantoro@yahoo.com
43 Jon Ungphakorn NGO Thailand ungjon@usa.net,
ujon@truemail.co.th
44 Nilawan Upakdee Naresuan University Thailand nilawanu@nu.ac.th
45 Jain Weraphong Naresuan University Thailand jweraphong@hotmail.com
46 Marius Widjajarta Dr. YPKKI Indonesian and Health Consumers
Empowering Foundation Indonesia ypkki@chv.net.id
47 C.A.K. Yesudian Dean Research and Development
Tata Institute of Social Sciences, Mumbai India yesudian@tiss.edu
48 Yuliawati Sri Public Health Diponegoro University Indonesia lkmundip@indosat.net.id
50
ANNEX 3: Group work on comparative perspectives
Below, the outcome of the first group work on cross-country perspectives is reproduced in a minimally edited form. The
outcome was used as basis for the second group work on country-specific recommendations that has been integrated in the main
report.
Health Care Seeking and Patient Rights
Chair: Prof. C.A.K. Yesudian. Rapporteur: Nupur Barua. Members of the group: Indonesia: Roy Tjiong, Widyawati Muhasin,
Siwi Padmawati. India: CS Pandav, C.A.K. Yesudian, Nupur Barua. Thailand: Dr. Angkhanaporn Sprnngai, Panada
Taechasubamorn, Vorasith Sornsrivichai. Observer: Mark Nichter (USA).
INDIA INDONESIA THAILAND Lessons learnt /
recommendations/conclusions
What do you see as
the three main
problems/needs
related to health care
seeking and patient
rights?
1. Access – location
and quality of
public facilities.
Raising levels of
credibility of the
formal system -
‘nothing in the govt.
system ‘works’
2. Less-than-qualified
practitioners
providing
questionable
(dangerous)
treatment to fill the
gap – issue of
patient safety
Networks (?cartels)
between various
levels of health care
providers
(Practitioner -
1. Self- medication
very high. Delay
– TB, ARI
2. Patients demand
for health service
leads
practitioners to
give irrational
treatment
Quick fix –
practitioner
pressure
3. Patient rights:
(Accessibility and
affordability of
the health
services)
1. Lack of
knowledge of
patient rights for
services
2. Unrealistic
expectations and
dissatisfaction;
low quality of
care if free
3. Accessibility and
Affordability of
the
Health service
1. How to raise the
credibility of the public
system. Study from the
patient and provider
perspective
2. Documenting legislations
related to patient rights
and safety and their
implementation status
51
diagnostic centres -
nursing homes)
What do we do?
(rid, regulate, train)
3. Lack of awareness
of patient rights
(quality of care)
Out-of-pocket
medical exp and
complete lack of
health insurance
Please describe
recent/current/planned
initiatives have been
taken to address these
issues, if any.
1. National Rural
Health Mission
Private Practitioners
Urban Health Task
Force
Recent
announcement
about an Urban
Health Mission
2. Legal Framework
Delhi Med
Council Act
Consumer
Protection Act
Other State Acts
3. Govt. and Private
sector health
insurance initiatives
(initial stages)
1. Community-
based organizations,
for instance, Desa
Siaga (village alert),
PKK (women’s
group), Integrated
Health Posts, and
school Education
programmes
2. Insurance for the
poor
3. Patient awareness
- Communication
information and
education
programmes
1 Community – base
approach and holistic
approach to identify
the health problem in
each age group and
improve the quality
of care to raise the
reputation of service
2. To educate and
mobilize the people to
know their right
3 Create self help
group and network
for illegal migrant,
elderly, etc
4. Provide global
fund for
Illegal migrant,
deserved people
5 Collaboration
between sectors for
proactive care
Please identify the Governance issues: 1. CBOs – need 1. Lack professional
52
main difficulties
related to successful
implementation of
these initiatives?
Provide examples of
successes and
failures.
1. Lack of political
will
2. Corruption in the
system
3. Translating
legislation into an
implementing
missionary
4. No accountability
Examples of successes:
1. Marwari Mat.
Hospital in
Guwahati
2. LIP in Kolkata
Failures:
1. Absence of
recognition of urban
poor as group with
specific needs and
design of
programmes FOR
the urban poor
2. Focus on averages:
disaggregated
analysis absent
absence of
recognition of
differences between
registered and
unregistered slums
strong
leadership and
some budget
2. Insurance – need
proper
identification
and targeting
3. Needs media
channel to reach
the people, incl.
human resources
-
Communication,
information and
education
(no, proper
allocation)
2. Discrimination to
provide service for
the people
3. Has a network
between the provider
and the community
Example of success :
1. case net work
between sectors at
Samuthprakarn
province
53
Health Care Seeking and Patient Rights
Chair: Dr.Deoki Nandan. Rapporteur: Yati Soenarto. Members of the group: Sanjay Gupta, Deni Sunjaya, Soenarto Sastrowijoto,
Marius Wiojajarta, Corul Anwar, Sakchai, Somsak Lolekha, Sirinard Nipaporn, Bupawan Phuaphanprasert, Reidar Lie
INDIA1.neglcgent+ INDONESIA THAILAND Lessons learnt /
recommendations/conclusions
What do you see as
the three main
problems/needs
related to health care
seeking and patient
rights?
1 Low understanding of
existing rule regulation
in private sector
2 legislation for
infrastructure.
3. No separate
legislation/ regulation for
private sector.
Inequality in patient right
Lengthy procedure for
justice
4. Human right
commission, women
right commission.
5. Medical council act
6. No: proper guideline,
control, evaluation
1. Right: Legislation
is available, no
implementation Low
capacity of the local
government. although
already
decentralization.
2. Difficult to
implement the
regulation;
monitoring,
punishment are not
recommended/clear.
3. Rights related to
private health care is
available but not
similar across private
and public sectors
1.The law is
available, but
enforced only for
private sector all
are being
controlled Æ
quality is better
than the public
sector
2. Inequity: limit
private in
limit/target.
Society fix.: not
available. Gender
equity
2. administrative
staff: in private,
sector are not MDs,
whereas in public
sector, they are
more MDs
1. There is lack of MONEF
(monitoring and evaluation),
however, norms are used,
Initiative: develop its MOU.
2.Over regulation as bed as
under regulation
3.several initiative have been
conducted: CPD, research, etc
4. PPP (Private-public
partnership) should be
developed
Compilation of document and
dissemination of
rules/regulation
Please describe
recent/current/planned
initiatives have been
taken to address these
issues, if any.
Abolition of quackery
NRHM:
• Decentralization
• Public-Private
Partnership
Advocacy by NGO’s
Local government and
parliament develop
act appropriate with
local issues
Improving local
government capacity
concerning regulation
function.
Research: private
should be approved
by MOH. Whereas
pubic/university
can do by
themselves. Now
improved---less
trust. Even color
54
-advocacy fr0m NGO
and private of the private hosp
is certain color,
given by the MOH
Please identify the
main difficulties
related to successful
implementation of
these initiatives?
Provide examples of
successes and
failures.
Corruption and
community awareness
-
Solution: specific
regulation and legislation
for private sect and
independent body for
monitoring
Corruption and
community awareness
Solution: specific
regulation and
Policy is always
TOP-DOWN Æ
Now, by the
initiative of Med.
council, all health
professional
societies creates
initiative proposed
to the government
Private health care delivery and quality of care
Chair: Ashok Kumar. Rapporteur: Jenifer Lobo. Members: Andreasta Meliala, Mubasysyir Hasanbasri, Yuliawati, Anil Purty,
Petcharee Reungon, Dounghathai Janchua and Aumnoay Pirunsarn
INDIA INDONESIA THAILAND LESSONS LEARNT
Three main
problems/needs related to
private health care
delivery and quality of
health care
1. Rapid Growth of RMP
and Unqualified persons
2. Lack of continued
upgradation of knowledge
and skills
3. Unequal geographical
distribution in rural,
urban and remote areas
4. Inadequate linkages
with Public health system
5. Lack of standards of
quality and fee structure
1. Lack of public health
responsibility
2. Rejection of poor
patients
3. Uncontrolled/varied fee
structure
1. Inaccessibility to poor
2. Lack of monitoring
and evaluation
3. Over-treatment and
expensive treatment
1. PP need to be involved
in the national health
challenges
2. Equal Geographical
distribution of PP
3. Clearly defined quality
of standards and fee
structure to be ensured
4. Monitoring and
Evaluation system to be
defined and ensured
Describe recent
planned/current initiative
to address these issues
1. Launch of NRHM, and
NUHM- infrastructure,
delivery of care, quality,
outreach with PPP and
1. Licence to practice has
been simplified
2. Insurance system
extended to PPs so that
1. Social Health
Insurance for workers-
limited coverage and
claim
1.Co-ordination of
multiple agencies is a
challenge
2. Registration of health
55
Public health standards
2. Re-registration of RMP
every 5 yrs after CME
3. Orientation of rural
medical practitioners
4. Review by GOI of
various regulatory
councils
poor are served
3. Assignment of specific
health care in the
community they are
serving
2. Licence for doctors
and nurses
3. Private clinics and
hospitals registered
4. Private hospitals
accredited
care workers is possible
3. Identify the main
difficulties related to the
successful
implementation of these
initiatives. Examples of
a. successes and
b. challenges
1. Lack of mobilization of
resources to implement
NR/UHM in the states
2. Inadequate review by
MCI of State councils
3. Inefficient
implementation and long
drawn out regulatory
mechanisms
a. Decentralization to
district and PRI to ensure
PPP
b. Implementation due to
large population, area,
diversified geographic
and socio-cultural factors
1. Lack of resource and
willingness to participate
In public health activities
2. No independent
monitoring agency
3. Lack of public agency
to follow up complaints
4. Lack of consistency of
NGOs to help the poor.
5. Lack of eligibility
criteria for poor to be
covered by social
insurance
1. Lack of Community
awareness of benefits of
social insurance schemes
extended to PPs.
2. Lack of infrastructure
to monitor accredited
hospitals
1.Monitoring
mechanisms are difficult
to implement
2. Mobilisation of
resources (human and
finance) is a challenge.
Health Financing
Chair Rama Baru. Rapporteur: Siddarth Aggarwal. Group members: Laksono Trisnantoro, Yulita Hendrartini, Supasit
Pannarunothai, Nilawan Upakdee, Kira Fortune Jensen, Dr Rama Baru, Siddharth
INDIA INDONESIA THAILAND Lessons learnt /
recommendations/conclusions
What do you see as the
three main
problems/needs related
health financing and
equity?
Primary care/OPD:
The poor mostly go
to private, including
less qualified
practitioners and
drug stores
Primary care/OPD:
the poor mostly go to
Govt facilities and
few go the private
Hospitalization care:
Mostly poor receive
Primary care/OPD:
mostly poor go to
private facilities,
including not so
qualified and drug
stores
56
57
Hosp: the poor go
to public more often
and less often to
private
care at public
hospital
There is a VIP/paid
Pvt ward being
introduced in most
hospitals, which
provides more
financing to the
hospitals and this
improves care to the
poor as well.
Hospitalization: poor
mostly go to public
sector
Please describe
recent/current/planned
initiatives have been
taken to address these
issues, if any.
Janani Suraksha
Yojana (for
delivering women)
Health insurance
for the poor under
NRHM
State Govt. schemes
e.g. Chiranjeevi
scheme - Gujrat
Poor family scheme
(National Govt)
Social Security
System
Local Municipal
Schemes
complementary to
those un-insured by
‘poor family’ scheme
Universal coverage
program
Focus on
infrastructure and
manpower
Please identify the main
difficulties related to
successful
implementation of these
initiatives? Provide
examples of successes
and failures.
Universal coverage
scheme for all
sections of society:
free for all people
Mostly curative
Separate budget for
preventive care
No co-payment,
completely free
Focus on
strengthening
infrastructure and
human resources to
bridge gaps
Have VIP wards at
Similarities:
Mixed service provisioning
and financing
Access and utilization of
services are different across
countries
Challenges:
How to bring doctors to the
remote areas?
Poor distribution of human
resources and infrastructure
Poor quality of services deters
slum dwellers to avail
services
58
hospitals to improve
overall quality at
hospital
Thailand made a
small increase in
taxation which was
utilized for providing
resources for
universalization
Enforcement of
referral system has
helped Thailand to
encourage utilization
of funds
Examples of
community based
health financing
initiatives
Lack of resources on
preventive care
