Dr Pramod K Singh
Institute of Rural Management (IRMA),
Email: [email protected]
The paper tries to discuss the governance issues involve in delivery of health care in rural India. It proposes Spatial Health Management Information System (SHMIS) for India and ways and means for its creation. The present healthcare delivery system in India is highly selective, institutionalized, centralized and top-down. It has failed to address the need of the majority of rural poor and marginalized.
The main governance issues related to health sector in India are mobilization of physical infrastructure; access, accountability and transparency; issues related to human resource motivation and gender concerns. Access to healthcare is hindered not only by geographic, social and cost barriers, but also by inherent systemic and structural weaknesses of the public healthcare system, some of them are as follows:
• Compartmentalized structures and inadequate definition of roles at all levels of care; inefficient distribution, use and management of human resources so that people have to contend with lack of key personnel, unmotivated staff, absenteeism, long waiting times, inconvenient clinic hours/outreach, service times, unauthorized patient charging;
• Inadequate planning, management and monitoring of services/facilities; displaying insensitivity to local/community needs; ineffective or non-existent referral systems, resulting in under-utilization of PHCs, over-utilization of hospital services, duplication; of services and cost-ineffective provision of services; inadequate systems to enforce accountability and assure quality;
• Inadequate attention to health education and public disclosure.
The mandate for contributing to universal access to quality health care services with accountability is a challenging task. Looking at the current national scenario of access and accountability of rural health care delivery system, it can be concluded that neither the public nor the private services come anywhere close to acceptable standards of quantity, quality and accountability.
Under the circumstances, our search is for a model that makes for a just health care system as an ideal for rural India, the main criteria for this could be:
• Universal access, and access to an adequate level, and access without excessive burden;
• Fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity and a constant search for improvement to a more just system;
• Training providers for competence, empathy and accountability, pursuit of equally care and cost-effective use of the results of relevant research; and
• Special attention to vulnerable groups such as children, women, disabled and the aged.
In order to tackle the above issues, an enormous spatial and non-spatial data will be needed, which could be integrated in a Spatial Health Management Information System (SHMIS). However for creating an SHMIS, one needs to understand the structure and configuration of public health care delivery system in India.
The Ministry of health and Family Welfare is the apex executive organization dealing with the issues of health and family welfare in the country. It also lays the national health policy in accordance with the policy decisions of the Cabinet. Health is the state subject in India and the Ministry of Health and Family Welfare acts as a coordinator between the state health departments, Planning Commission, central council of health etc. besides implementing various national programs and items under unions list and concurrent list. In the process it is aided by the Directorate General of Health Services. Health administration at the apex level of the Government of India consists of Secretary for health, Secretary for Family Welfare supported by Additional, Joint secretaries who are drawn from the Indian Civil Service. The rest of the organization is mostly program/project based. Ad hoc project structures such as TB project or Malaria project etc., are created as and when necessary. Since state governments implement the projects and deliver the regular health services they have fairly well demarcated systems. Separate directorates or head offices usually exist at the state capital for primary, secondary and tertiary health care which includes medical colleges and medical education. Many states have separate structure for family welfare operations since population control through family planning is given great importance. At district level, health administration consists of number of officers and doctors who on an average handle 10 to 15 hospitals, 30 to 60 primary health centers and 300 to 400 sub centers. The entire complex arrangement results in a number of vertical channels of information; multiplicity of agencies, dual reporting systems etc. (Bodavala, undated).
Hence the SHMIS would be located at the Ministry of Health and Family Welfare in the Government of India. There would be a server at this location which would accumulate the meta-data and also having accessibility to other servers. This server would be linked to NSDI server. Apart from the central location there would be servers located at state and district level with the Health Administration Department. The hospital information network would be connected to the server at district level thus the district lever server would be ready with online real time updating. The Research Institutes and medical colleges will have servers which would be linked to either state level or directly to the central server depending on the operational area of the institute. Other players like Pharmaceuticals, Civil Societies can also have their information network linked to anyone level (national, state or district). The district level server should also be updating taluka-wise and village-wise epidemiology and health infrastructure in the district. While this would provide a proper information flow, the decision system would be much more effective with the enriched analytical ability of GIS. The following model of information system aided by GIS can help in better delivery of health services:
• It would not be required for every agency to provide all types of data to the next level. It will have the discretion to filter the information by classifying shared and unshared data. e.g. every admission record at hospital need not be communicated to the next level, rather only the aggregate data may be shared.
• This will decrease the cost of storing and analyzing the information at the actual source thus avoiding duplication and also be accessible through internet at the time of need for the user, may it be a household in the community or be any institution.
• The user can access the data of any level by logging into the central server without having the hassle of visiting every website. It can act as a single-window service station.
• At each level, data would be viewed geospatially, which would help to take rationale decisions and hence better health care.
Once SHMIS is in place, the governance of health services and infrastructure in rural India will be easier.