PSIREN

The experience of health sector reform in South Asia presents certain common trends but also variations in terms of the political economy and health services development in the four countries (Sri Lanka, Bangladesh, Pakistan, India). Soon after independence the governments of all the four countries had committed themselves to investing and building a welfare state governed by principles of equity and social justice.  Except Sri Lanka, which managed to build a universal and free welfare service, the others did not make the required investments in the welfare sector, especially health.
 
The global recession during the late seventies had an adverse impact on public spending and this resulted in either a cutback or stagnation in investments in health across all these countries.    This had serious consequences for public services and in fact created spaces for the growth of the private sector. During this period there was a shift in policy in favour of privatisation by offering concessions and subsidies to encourage the private sector, across all the countries in the region.
 
The role of multilateral agencies like the World Bank and IMF furthered the privatisation agenda by influencing national health policies under the Structural Adjustment Programmes (SAPs). The centrality of public provisioning shifted to greater role for markets – (a)  Individual, charities and private organizations should be made responsible for health care;  (b)  Public funding must be restricted to health promotion and prevention of disease;  (c)  Central government’s role should be restricted to policy formulation and technical guidance, with delivery of services left to the private sector and local authorities;  (d) Private and non- governmental sector should be supported to become the key providers of health and social services.  The SAPs not only advocated policies for a greater role for private health services but also introduced structural changes in the public sector by introducing market principles like user charges, contracting out, importing high technology equipment etc.   Medical officers and other technical officers within the state health sector to practice privately, outside their working hours, with no effort to regulate or ban it.  Even the nascent private sector was unregulated and therefore grew in a haphazard and uncontrolled manner. As far as training of doctors and paramedical personnel was concerned, the state started encouraging the establishment of private medical colleges.   This meant that those trained in private colleges were interested in finding jobs in the private sector.  Privatisation in highly inequitable societies like South Asia is bound to marginalise access to the lower middle and poorer sections, which constitutes around 30-60 percent of the population.  Some studies show that the middle class in India and Sri Lanka has largely moved away from public provisioning in favour of for-profit care and it is the poor who use public services.  The indirect costs for even publicly-provided services are increasing and there is evidence that there maybe section of the population who may not be able to afford even these services.
 

• In Sri Lanka, health sector reform initiatives were put in place when the government offered direct concessions to the private sector, including:  Permitting foreign providers of medical cares to operate in Sri Lanka;  Encouraging private health insurance industry; Leasing spare capacity in public facilities to private practitioners;  Offering concessional loans to private practitioners to establish practice in rural areas.

• The Structural Adjustment Program implemented in Pakistan in 1988 squeezed public expenditure on health, with little expansion of facilities and manpower, which further paved the way for privatisation. 

• Among all the South Asian countries, India has the largest private sector and is an exporter of tertiary corporate health care to others in the region. While Bangladesh, Pakistan and Sri Lanka have a very small presence of institutions at the secondary and tertiary levels, India has a fairly large private sector at these levels, marked by regional variations.  Several states within India have been appointing doctors on contract basis in order to overcome the shortage of personnel in rural areas.  There is a shortage of paramedical workers as well due to a freeze on training and recruitment of various categories of these workers.  The solution to this impasse has been to introduce multi-skilling of existing workers or to encourage community health workers on a voluntary basis with a small honorarium.

 
[Source:  “Health Sector Reform in South Asia: A Comparative Analysis,” By Rama V. Baru, Jawaharlal Nehru University, New Delhi (India), 2008.]