1. INTRODUCTION
Health sector reform is a sustained process of fundamental change in policies and
institutional arrangements of the health sector1, usually guided by the government. The
process lays down a set of policy measures cove ring the four main core functions of the
health system, viz., governance, provision, financing and resource generation. It is aimed at
improving the functioning and performance of t he health sector and, ultimately, the health
status of the population.
Health sector reform deals with equity, efficiency, quality, financing, and sustainability
in the provision of health care, and also in defining the priorities, refining the policies and
reforming the institutions through which policies are implemented.
Meeting the essential health needs of t he people has always been the goal of all
governments in the WHO South-East Asia Region (WHO SEAR). Exactly two decades after
the quest for health for all was set in motion at the World Health Assembly, the Health
Ministers from Member countries of WHO SEAR, at their 15th meeting in August 1997
adopted the Declaration on Health Development in the South-East Asia Region in the 21 st
century. In this declaration, while realizing the challenges that lie ahead and the
opportunities and potential of further enhancement in health development, the Health
Ministers expressed their deepest concern and unstinting commitment to ensure access to
health care to all. They affirmed the principles and strategies of health-for-all while reiterating
that health is central to sustainable development and well being.
The Ministers noted that the foremost challenges in the Region in the 21st century and,
particularly, during next few decades, were: in initiating health sector reform to reduce
inequities in health; creating conditions that promote health and self-reliance; ensuring basic
health services to all, and upholding and enforcing health ethics. The Ministers agreed that
the governments have the main responsibility to overcome these challenges in partnership
with other sectors and the community. The Ministers also highlighted a few priority reform
activities, including attacking priority dis eases causing high morbidity, mortality and
disability; providing essential health care to all; investing in women’s health and
development; making appropriate application of scientific knowledge and technology; and
enhancing community participation.
At its 50th session in September 1997, the Regional Committee endorsed the Regional
Declaration and noted the recommendations of t he technical discussions on “Health Sector
Reforms”. The Committee recognized that reforms in health sector were needed to attain the
universal goal of health-for-all and in ensuring equity, solidarity and social justice. Rapid
political and socioeconomic changes and the demographic and epidemiological transitions
underway had accelerated the reform process. While some countries had initiated
fundamental changes, others had initiated sequential, evolutionary, and incremental
changes in the policy, organization and management of health systems. Through a
resolution2, the Regional Committee urged Member States to explore effective strategies for
the political and administrative management of the process and content of health sector
reform and to involve policy makers, providers of health services and the public in this
process.
The Committee also requested the Regional Director to promote exchange of
experiences on health sector reform through appropriate consultations, documentation and
dissemination, including the use of national and international institutions, WHO Collaborating
Centres and other technical forums, with a critical assessment of all aspects of the impact of
such reforms. The progress made in the area of health sector reform and their impact in the
Region are analyzed, reviewed and discussed in the following paragraphs.
2. ISSUES IN HEALTH SECTOR REFORM
From an analysis of health sector reform in the Region and elsewhere, it is seen that there is
no consistently applied, universal package of measures that constitutes health sector reform.
The process of reform is also proceeding rapidly in many countries. While considering
health sector reform, new forms of relationships among the components of health systems
can be developed to make complex changes and interactions. During the last few decades,
most of these efforts are being spurred principally by a desire to improve equity and quality
of care, to expand coverage, to decentralize health care management, and also to contain
costs. The reforms sometimes are highly political and fiercely contested processes.
in some countries, the reforms became more complex due to the presence of a wide range of
contracting partners, including external agencies. While every reform experience is country-
specific and usually based on solid evidence, there are important lessons to be learnt from
comparing options, identifying common issues addressed and the tools used, and evaluating
effects of various reform initiatives.
Most countries usually focus attention on the contents of the reform, rather than on the
process. This focus on content runs the risk of equating health sector reform with one set of
prescriptions, e.g. the introduction of market mechanisms; user charges; establishing joint
management bodies with low responsibility; reduc ing the size of the public sector; cost-
containment and redistribution of resources.
The reform usually ignores the question offeasibility of implementing the change. W hat is needed is to increasingly understand theissues in reform processes to complement what has been learned about the content of
reforms. Such an understanding might lead to the development of strategies for publicizing
or marketing reforms or identification of ways that governments can anticipate and plan for
the reactions of organized interest groups.
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2.1 Health care financing reforms
The most striking reform in the health sector concerns securing sustainable financing for
health care. When health sector investment is analyzed, it is seen that the situation over the
past few decades has not changed with regard to low investment in health. According to
recent national health accounts data as report ed by WHO, the total health expenditure in
most countries of the Region is around 2-8 per cent of their GDP.3 The proportion of
government contributions as a percentage of total health expenditure in most countries
ranged from 20-60 per cent, depending on the growth of private health care systems in
respective countries. A worldwide study 4 on external assistance to the health sector during
1972 to 1990 revealed that smaller and poorer countries received more funds from external
assistance in health sector per capita than larger and richer countries. Around 20-30 per
cent of total health expenditure of least developed countries such as Bangladesh, Bhutan
and Nepal comprised of external assistance.
The national health accounts provide useful insights to governments to review how they
can and should allocate public resources for health, what should be the level of public and
private expenditure, and how private resources can be mobilized for public healthexpenditure.
A careful analysis could be made to determine what types of financing
strategies are to be adopted, e.g. mobilizing financial resources within the health sector,
outside the health sector or improving the use of existing resources. Health care financing
reforms have to be initiated in order to ensure equitable access and efficient and effective
health care. An appropriate mix of private and public health care and financing mechanisms
have to be established, so that the two sect ors complement to each other, to yield best
results.
Alternative health financing reforms such as cost-recovery and cost-sharing schemes,
user fees/ charges, community financing, heal th cards or voucher systems, subsidized
payment schemes, contracting se rvices, social insurance sc hemes, and private insurance,
etc., are some examples of changes in financing mechanisms introduced under the umbrella
of health sector reform. Most countries have concentrated on the contents of reforms in
health care financing rather than on the processes resulting in failure or delays in
implementation.
The fundamental principle of financing reforms is that health care funds (either for
private health care or for community health prevention and promotion) are raised from the
people according to their ability to pay, and not according to health need. It is also equally
important that funds are spent according to health need, and not according to ability to
pay. Everybody is entitled to pay an equal share of disposable income. This not only
depends on the share of disposable income spent on health, but also the methods of
financing, such as general taxation, insurance, or out-of-pocket payments. Fair financing
deals with whether funds are raised through a progressive collection mechanism and
protection of catastrophic health costs.
Even though the level of health spending (like total health expenditure or per capita
heath expenditure as percentage of GDP) is important, experiences of some high-and
middle-income countries show that more is not always better or always possible. What
needs to be kept in mind is how far health expenditure is distributed according to health
needs. The effects of good spending and utilization according to health needs are reflected
in the level of inequities in health.
1- Students will select a state health policy reform innovation: The health policy reform innovation selected is: Healthcare Reform News Update for May 14, 2019: Washington Creates Country’s First State-Run, Long-Term Care Benefit Program
Students should summarize their findings in a 1-2 page, single-spaced memo. The Memo is required.
Sample memo provided by the professor is attached. Also It is attached the   ACT Relating to long-term services and supports; This link provide an article from The New York Time  https://www.nytimes.com/2019/05/13/business/washington-long-term-care.html