Geneva Health Forum Archive

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Community-health insurance in Rwanda: equity, quality and financial viability.

Author(s) Bonaventure Savadogo1, Joelle Shwarz2, Manfred Zahorka3, Florence Secula4.
Affiliation(s) Swiss Center for International Health, Swiss Tropical and Public Health Institution, Democratic Republic Congo, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel, Switzerland, Swiss Center for International Health, Swiss Tropical and Public Health Institution, Basel,Switzerland, 5.
Country - ies of focus Rwanda
Relevant to the conference tracks Advocacy and Communication
Summary Rwanda has launched three prominent reforms in the field of health financing since 2000, which have shown significant results in increasing both the supply of and access to services. The fiscal decentralisation, the community-health insurance (mutuelles de santé), and the performance-based financing (PBF) have largely contributed to the fact that Rwanda is on good track in reaching the targeted health MDGs.
Funded by the Swiss Cooperation and Development Office since 2002, the Programme de Santa Publique – PSP (Public Health Programme) aims at strengthening the health system in two districts (Karongi and Rutsiro) in the Western Province.
What challenges does your project address and why is it of importance? In the context of Rwanda, one of the main challenges is to reconcile the necessity to mobilise resources to ensure the financial viability of health services with a context of wide-spread poverty.
In the two districts of intervention, the project supported the setting-up of pilot mutuelles by providing management training for the staff of the mutuelle sections (sections are located within each health facility) and the mutuelle directions (at district level). This was done  by providing tools, registrars and equipment and by monitoring the performances of sections and directions, as well as the financial flow between them and the health facilities.
Early on, the project sought to include the dimensions of equity within the scheme and this was enacted by financially supporting the administrative districts to set-up the identification process of indigent people, and in turn by subsidising adherence fees and co-payments to health services utilisation via the mutuelle sections. This reduced health access barriers for this group. However, as close to 1/4th of the population is identified as indigent, a sustainable equity mechanism in covering the costs of the scheme (and not by external subsidising) is yet to be found.
How have you addressed these challenges? Do you see a solution? Though previously scaled upon the basis of the socioeconomic status of households, the adherence fee has been fixed since 2007. This scheme does not allow a cross-subsidising of costs across the population. The PSP has supported a community solidarity mechanism for such cross-subsidising in each district. The Ikimana system is the grouping of 25 to 50 households into community associations where members motivate one another to pay their fees and assist members that are less well-off. This system has substantially raised the coverage of mutuelle in the two districts and shown that commitment and solidarity can be fostered amongst small groups who share a common reality. Policy dialogue has been conducted for the project about the gradual withdrawal of the subsidisation of indigent people in favour of other sources of funding, such as the Ikimana system. However, the taking-up of those groups by Ikimana has to be monitored in order to ensure that people are not left behind.Support of quality of care is challenging as because from the beginning the quality has always been relatively low due to the limited resources (financial, human and infrastructure) and the remoteness of some facilities. The concomitant reform introduced, Performance-based Financing (PBF), is expected to correct the negative effects of the utilisation increase by motiving the performance of the health staff in the facilities through incentives. However, most incentivised indicators of the PBF scheme are quantitative rather than qualitative. Ensuring a good quality of care is of primary importance to maintain the high adherence rate and the satisfaction of the insured. The PSP has supported the establishment of a monitoring system of quality of care (structure, process and results). It has also supported the conduct of client satisfaction surveys, which have shown fairly good levels of satisfaction. The project has also repeatedly conducted quality of care assessment in the intervention zone to evaluate the situation.
How do you know whether you have made a difference? The PSP cannot claim to have made a difference on its own. The programme aims at supporting national policies and strategies. It has been observed in the two districts of intervention that the mutuelle adherence uptake is observed to be parallel with a marked increase in the utilisation rate, as well as an increase in the proportion of the indigent people within the general population that benefit from a free adherence card. The implementation of the mutuelle has not followed an experimental design, therefore establishing causality in the positive developments is not possible.
The PSP supported Karongi district was declared a model district in 2010, and has received a visit from the central level Mutuelles Technical Working Group. Other districts have subsequently visited Karongi’s direction and sections, to learn from their organisation and experiences. The mutuelle sections in the two districts are well organised, equipped and coordinated (at the national level), and they manage to cover the costs for the primary level.
At the national level, studies have shown that catastrophic expenditures have declined for all groups of the population. The approach has revealed not to be pro-poor, but neither pro-rich (Lu et al, 2012). In 2010, the government introduced a new measure to induce an increase in the utilisation by the poorest sections of the population by reducing the co-payments for such groups.
Have you or the project mobilized others and if so, who, why and how? Firstly, the staff from the mutuelle sections and directions have been mobilised through the project. They have been trained, equipment and tools have been provided, and their performance has been monitored in order to provide tailored support. The support in their establishment as federations has also helped the coordination and organisation of their services in efficient ways. Ensuring the smooth functioning of mutuelle sections was a condition for the health facilities to remain financially viable.  The project is structured so that the health services can be reimbursed by the sections of the health facilities. Delays in reimbursing the costs, as seen at the level of hospitals, can jeopardise the capacities of the health facilities.
It is undeniable that the observed success of the mutuelles in Rwanda is linked to the national political context. The government has declared adherence to a mutuelle as mandatory, and strong political will, with support from donors,  has pooled the funds to ensure the establishment of the scheme and its financial viability in the first years. Setting performance targets for the local administration that included the increase in the adherence to mutuelles has also contributed to a very high coverage rate. Furthermore, Rwanda after 1994 has benefited from large external funding (in 2009, external funding represent 46% of the total health expenditures), which has facilitated the scheme's implementation.
When your donor funding runs out how will your idea continue to live? Most of the support in implementing the mutuelle scheme in the two districts has been enacted in a way that the districts have substantial control. Direct financial support has been phased out between 2002 and 2013, and today the fees for indigent people are partially covered by communities through the Ikimana system. The district mutuelles are financially supported at the central level, with funds from the government and it’s partners such as the Global Fund.
The remaining main challenge is quality assurance. Continuous support is needed to ensure that the district level supervises and monitors the quality of care in the facilities. Supervision and monitoring of the financial flows are needed from the central level down to the district (directions) and the facilities (sections) to ensure the scheme's viablity.
The challenge for the mutuelle scheme is financial sustainability.  Political instability in the region, mainly in neighbouring DRC where Rwanda plays a role, raises the concern of the international community and external funding may become fragile. Currently the financial viability of the system relies upon external funding, and if it diminished, financing the scheme at the secondary and tertiary levels could be at stake.

Breast cancer screening for everyone.

Author(s) Patrick Brander1, Marius Besson2, Béatrice Arzel3
Affiliation(s) 1Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 2Service de médecine de premier recours, University Hospital Geneva, Geneva, Switzerland, 3Fondation genevoise de dépistage du cancer du sein, Fondation genevoise de dépistage du cancer du sein, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Social Determinants and Human Rights
Summary As breast cancer is the most prevalent cancer in women, a screening program has been developed in the canton of Geneva since 1999. The University Hospital’s CAMSCO service (Consultation ambulatoire mobile de soins Communautaires) is devoted to people living in precarious conditions which includes mainly undocumented migrants and women working in the domestic’s fields, those without health insurance, and inclusive of those aged over 50 years old. Since 2006 a collaboration between the cantonal breast cancer screening program and the CAMSCO was developed allowing for these undocumented women to have access to information in their own language and also mammography screening. Since 2008 280 women have had mammography screening.
What challenges does your project address and why is it of importance? Access to health systems for undocumented migrants in Switzerland is difficult and differs greatly between cantons. Some swiss cantons have organized a system to allow these people to have access to primary care and preventive medicine. Breast cancer screening is recommended by international guidelines and should, as such, be offered to every women between 50 and 74 years old.
How have you addressed these challenges? Do you see a solution? A collaboration between the CAMSCO and the “Geneva Breast Screening program” has been developed since 2006, allowing the undocumented women between 50 and 74 years old and living in Geneva to be offered mammography screening. This program is financially supported by public funds and the mammography itself is paid 90% by patients’ insurance with a 10% (19.15.-swiss francs) contribution by the patient. The exception is disadvantaged women, for whom this amount is supported by screening program through private funds.
How do you know whether you have made a difference? Due to this collaboration 280 migrants women without health insurance had access to mammography screening. Their number has been about stable since 2010 averaging 65 for each year.
Have you or the project mobilized others and if so, who, why and how? The project has mobilized the Geneva hospital gynecology service as they do the mammography and assure that any anomaly is investigated and treated as needed. Medical doctors working in the Geneva hospital primary care service are also encouraged to plan mammography for their undocumented migrants as indicated
When your donor funding runs out how will your idea continue to live? Our collaboration may be funded by public funds, as it is already in part. Otherwise, it could only be funded by patients themselves, which is impossible.

Patients on the Move

Author(s): M. M. Kingma1
Affiliation(s): 1International Council of Nurses, Geneva, Switzerland
Key messages:

1 – Globalisation is affecting the health sector - expanding the health services provider market as well as the health professional labour market.
2 – Health tourism tends to introduce or facilitate the growth of the private sector health industry. This may result in intranational tensions and competing vested interests.
3 – Health tourism needs to be monitored and evaluated in terms of population access to care, service stan- dards, and local labour conditions.

Summary (max 100 words):

The international migration of health professionals has increasingly been on the political agenda, especially in the context of widespread shortages of employed care providers. Globalisation is a reality and recognised characteristic of today’s world. Health systems are faced with the challenge of increasing demands on their services and a relative decrease in funding. Privatisation in the health sector is increasing, including in areas known as health tourism – patients seeking care outside their country of residence. Health facilities are being established providing medical and surgical interventions, as well as health promotion services (e.g. massage, relaxation therapy) essentially for foreign patients. While recognised as an income generating initiative in many cases, the introduction of health tourism may distort the public/private mix within the national economy, increase the intranational “migration” of health professionals from the public to the private sector, influence educational and practice standards, challenge professional regulatory bodies, place new demands on health insurance systems and create wide disparities among the pay and working conditions on offer locally. Health tourism may also help retain health professionals by providing better employment and professional development opportunities, improve working conditions, advance health care, harmonize standards of service delivery, and disseminate evidence-based practice.

Conclusion (max 400 words):

Health tourism is on the increase and predicted to be a growth industry in the years to come. Its introduction influences aspects far beyond health care, including the national economy, education, regulation, access to and quality of public sector services, insurance companies’ sustainability, the tourist industry and people’s expectations. Health tourism needs to be monitored and evaluated as a social phenomenon as well as studied in terms of impact on the accessibility and quality of care, patient outcomes, labour market and health personnel behaviours.

Global Patients, Global Doctors: Lessons from the Health System of the Maritime Industry

Author(s): D. Lucero-Prisno1
Affiliation(s): 1IMHA, Tacloban City, Philippines
Keywords: Maritime health, health system, seafarers, global health

The maritime sector is a highly globalized industry with an international workforce of 1.5 million seafarers working on literally all waters of the world. As a risky profession (second only to commercial fishermen), seafarers are exposed to a multitude of occupational and health hazards. This equates to USD 135 million of compensation for personal injury from the P&I Clubs (insurance) every year, which is more than the claims for maritime pollution. As ships ply their routes, medical services all over the world are always at bay waiting for patient calls once needed. These highly organized services are specifically designed for the industry with medical services provided regardless of the nationality of neither the seafare nor the medical staff, the flag of the ship, nor the port of call.


To understand how health services are delivered and provided to the global seafarers. To understand the framework governing the scheme of health service provision beyond nationalities and borders. To deduce learning from this industry for other ‘global’ health systems. To assess the weaknesses, strengths and gaps of the maritime health system.


The workforce of maritime industry is composed of seafarers from different countries with a big percentage from East Asia and Eastern Europe. Filipinos comprise almost a third. These seafarers work on ships flagged under different countries with Liberia and Panama on top of the list. Globalization paved the way to this scheme despite real ownership in other countries. For every tour of duty of the seafarers, a medical examination is required in the home country of the seafarer. This screening identifies those who are fit to work. The countries where the ships are flagged accredit these clinics. Insurance companies support this screening to avoid health claims from those who have existing health problems. These companies have a separate accreditation scheme of all the clinics where seafarers can go in case they are afflicted with a malady while on board or on contract. They can easily approach health services at different ports without too much financial worry. These clinics and hospitals make claims from the representatives of the shipping or insurance companies within the area. Despite the lack of international standards, the maritime industry is able to carry out its task of taking care of the health and welfare of its workers; though maybe not to a perfect degree. The International Maritime Health Association (IMHA) is the only international organization of health professionals who have direct contacts with seafarers. They lead the initiative of developing an international medical standard for the seafaring sector so that services and diagnosis will be similar throughout the world. WHO accredits four Collaborating Centres on health of seafarers based in Germany, Denmark, Ukraine and Poland. They are clustered under occupational health. WHO, ILO and the IMO have some collaboration in the area of health of seafarers. The industry observes ‘self-regulation’ and maintains certain standards without too much intervention from nation-states.

Lessons learned:

The health system of the maritime industry is an interesting model of a responsive and effective global health system beyond the consideration of the nationalities of neither the patients nor the health providers and without considering national borders. Though this study does not claim for it to be a perfect global health system, it has many characteristics that are worth emulating. Its well-organized structure allows easy access for its clients to quality health services. The major strength of the system is its strong health-financing scheme that is backed by a rich maritime industry. Quality and access are assured because of the good compensation given to the health providers. Keeping maritime workers healthy is imperative because they literally run 90% of the global trade.

Why Taking into Account Social Determinants is Essential to Reach a Successful Global Health Policy? An Example from the HIV-Care Sector in Burundi


J. Cailhol*1, T. Nahimana2, L. Munyana2, H. Ntakarutimana2, F. Musanabana3, D. Diack4, M. Dubreuil4, C. Arvieux5, O. Bouchaud1, T. Niyongabo2

Affiliation(s): 1Infectious and Tropical Diseases, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France, 2HIV-care centre, University Hospital of Bujumbura, 3HIV-care centre, Prince Régent Hospital, Bujumbura, Burundi, 4Project Department, ESTHER, Paris, 5Infectious and Tropical Diseases, University Hospital of Rennes, Rennes, France
Keywords: Social determinants; HIV-care; global health policy; international funding

Health policy usually targets epidemiologically defined population in a specific intervention programme. However, the sectorisation of health problems and the development of health policies, missing ‘surrounding’ socio-economic determinants, may result in inequitable long term results.


In Burundi, the HIV sector is mainly financed by international funding (IF), including the Global Fund (GF). By this way, HIV-infected people can have access to care, antiretrovirals and opportunistic infections medications free of charge. IF can also contribute to major the HIV-healthcare professionals (HCP) salary. Indeed, because of extremely low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. In Burundi, there are now less than 250 physicians left. Through three examples, we will attempt to demonstrate that health policies should consider social determinants.


Example 1: Burundi is one of the poorest countries in the world (more than 70% of the inhabitants earn less than 1 dollar per day): as a result, few people can afford a medical insurance. Apart from HIV-infection, in case of any disease, patients either pay by themselves, almost always helped by their community or remain without any medication. In governmental hospitals, physicians are aware that some common medications such as amoxicillin or cotrimoxazole are available through the GF and use these GF-drugs without regard to HIV status. This behaviour cannot be condemned as physicians cannot leave a patient without medication only because he is not HIV-infected. However, these medications are becoming out-of-stock quickly, and it is impossible to produce accurate estimations of the need in opportunistic infections medications. After all, who will be blamed by the GF for this misuse of a specifically HIV-dedicated funding?
Example 2: HIV-patients must be highly adherent to their medication to be successfully treated. Many patients, who are fully aware of the importance of the treatment for their own health, are forced to interrupt their treatment because they cannot afford daily food. A quick overview of temporary lost of follow-up patients revealed that most of them did not have any money for the monthly transportation costs to their care-centre. On the same way, sustained adherence to HIV prevention cannot be expected if poverty does not allow inhabitants a prospective sight. Indeed, why would they care for their tomorrow’s health if today they don’t have enough food for themselves or their family?
Example 3: Due to better funding in the HIV-sector, deleterious consequences can be expected for the general population and for HIV-patients as well. First, many physicians, even though scarce, are concentrated in the HIV sector, dropping other priority sectors (paediatrics, diabetes mellitus…). Among HIV-sector, well-trained physicians leave the public care sector to join up with international agencies (particularly the WHO and UNAIDS) and also NGOs. Sometimes, pair-educators earn better salaries than nurses or even physicians, leading to a demotivation and conflicts between HCP.

Lessons learned:

Lessons learned in the expanding access to HIV-care in Burundi, i.e. IF repartition and organisation of prevention and HIV-care may be applied to other sectors, leading to a global health policy. Health determinants are linked together and merged into social determinants. Ideally health policies should consider the whole population and its social determinants, instead of focusing on one particular group of diseased people. In concrete terms, for instance, using part of IF dedicated for example to TB, HIV and malaria (GF) to provide HCP viable salaries and medications for other sectors would probably result in a significant improvement of global health.

The Lived Experience of Family Caregivers Caring for Ventilator-Dependent Patients at Home

Author(s): Y. H. Wu*1, Y. H. Tseng2
Affiliation(s): 1Burn Centre, Changhua Christian Hospital, Changhua, 2Department of Nursing, National Taichung Nursing College, Taichung, Taiwan
Keywords: Ventilator-dependent, home care, qualitative research, family caregiver

Due to the ventilator-dependent patients occupied acute-care or intensive care units, Bureau of National Health Insurance (NIH) has carried out the ‘Integrated Delivery System’ plan since year 2000 to encourage ventilator-dependent patients to be cared at home. However, it was little noted about difficulties or problems that home-care patients and their families had met. The purpose of this study was to illuminate lived experience of caregivers caring for ventilator-dependent patients at home.


A qualitative research design was used. Data were collected by in-depth interview. Fifteen family caregivers who had the ventilator-dependent care experience were invited to participate in this study by purposive sampling. The interviews were tape-recorded and then transcribed word by word. Content analysis was used to analyse the data.


The result of the study emerged 8 categories of the experience of caregivers: (1) Deciding to care at home because of the intimacy relationship. (2) Preparing for a new life. (3) Developing strategies to reduce care loadings. (4) Experiencing various sudden/emergent events. (5) Performing medical treatments without medical orders. (6) Having heavy burdens on physical, mental, and social aspects. (7) Insufficiency in the fair of home care. (8) Contradictory feelings to the ventilator.

Lessons learned:

The results of this study could be used to refine discharge plan for home care of ventilator-dependent patients and their caregivers. The experience of the caregivers could be used by other families to make decision for home care. Moreover, the results may provide information for NIH policy reform about ventilator-dependent home care.

Workloads and Time Use among Health Staff in Rural Vietnam’s Commune Health Centres

Author(s): H. B. Duong*1, T. Q. Mai2, T. V. Bui3, J. Hughes1, J. Phillips1
Affiliation(s): 1Population Council, Hanoi, 2Thai Nguyen Medical School, Thai Nguyen, 3Can Tho University, Can Tho, Viet Nam
Keywords: Workload, time use, management, health workforce

Thanks to new national insurance policies, the last few years have seen a significant surge in the utilization of public healthcare at the commune level in Vietnam. Some commune health centres (CHCs), the primary healthcare destination for most rural residents, are experiencing double and in rare cases triple the previous average number of visitors. The increase in numbers has not only resulted in an increase in the amount of time health staff spend with patients, but also in the amount of time they spend on paperwork. At the same time, the number of health staff and their other workloads (e.g. preventive care) remain unchanged.


The aim of this research paper is to analyse current time utilization in CHCs by type of provider and patient volume at facilities. The paper also aims to provide a full account of CHC staff responsibilities and workloads.


Self-administrated anonymous questionnaires and logs of time use at 30-minute intervals were distributed to staff of all 107 CHCs in Vinh Long province, southern Vietnam in July 2007. These quantitative data are analysed alongside with observation and in-depth interviews about responsibilities and tasks with staff at 6 CHCs. The study provides a clear account of how CHC staff utilize their time, and how the division of labour and tasks is carried out in a typical CHC. All types of contacts with patients and local residents (including examination and care of patients, national programmes, baby delivery, maternal care, drug distribution, health education) account for only 50% of staff time. The rest of 50% is devoted to paperwork and report (14%), training (10%), rest (10%), meeting (8%) and other small tasks (cleaning, waiting for patients, taking care of traditional medicine garden, etc.). Although the time spent on paperwork and report is not as high as staff often complain, the types of paperwork and reports are incredibly large (each staff has to keep at least 10 notebooks and does almost the same number of reports on a monthly basis).

Lessons learned:

Two of the lessons learned from the research are: (i) while the key mandate for CHCs is to serve the residents, the amount of time spent on all types of contacts (for all curative and preventive care) is only 50%, which seems inadequate. Measures might need to be taken to provide with residents with more attention from providers; (ii) the reporting systems are too cumbersome, repetitive and everything is done by hand. There is a need to consolidate and computerize these systems to save staff’s time and efforts.

The Health Workforce’s Health

Author(s): M. P. Guillemin*1
Affiliation(s): 1Occupational Environment, Institute for Work and Health, Lausanne, Switzerland
Keywords: Occupational health, work organization, occupational hazards, stress

The World Health Assembly of the WHO has agreed in June 2007 on a Global Plan of Action in Occupational Health. The importance of healthy working conditions to promote a healthy workforce has been emphasized and countries are urged to develop their own National Policy for Occupational Health. This concerns all workplaces and is of particular relevance to the Health Systems where it is well known that occupational health and safety conditions are far from being satisfactory.


A short review of the situation related to the Health Workforce, as it is described in the scientific and professional literature, will stress the major problems. Among those requiring the most urgent control measures are: work pressure, stress, violence, ergonomic factors (loads for instance) as well as exposure to toxic chemicals (anaesthetic gases, antineoplastic drugs, disinfectants, etc.).


The WHO has created an international network of Health Promoting Hospitals. This represents a way towards progress in this field. A few examples of preventive measures, such as the ones related to the stress at work, will illustrate the importance to cope with such important challenges. The occupational health experts such as occupational hygienists, ergonomists, occupational physicians, occupational psychologists, occupational nurses have a role to play in the detection, evaluation and control of these problems. Therefore a transdisciplinary approach is necessary.

Lessons learned:

Occupational health is a big issue of public health and has unfortunately been confined in the much too restrictive area of social and insurance systems, up to now. It is essential that the importance of this broad field is better understood as well as the impact of inadequate working conditions on the quality of the health systems and on the global economy.

Physician Shortages in Canada – Medical School Graduates and Physician Retirement are the Tips of the Iceberg: A Change in Healthcare Policies is Required

Author(s): S. M. Kabene*1, J. Howard2
Affiliation(s): 1Management and Organizational Studies and School of Nursing, 2Schulich School of Medicine, The University of Western Ontario, Canada

Physician shortages, international medical graduates, aging, medical school admissions, healthcare policies


Since the late 1990s, there have been claims about the shortage of physicians in Canada. With Canada’s mean population age rising, a shortage of physicians may be a much larger problem than previously estimated a decade ago. The objective of this paper is to analyse some of the main causes of the current physician shortages in Canada and suggest some possible solutions.


Three main questions are addressed to analyse the shortage: How many physicians are practicing in Canada and have these numbers increased or decreased? What are the main causes of physician shortages? What are the main impediments to the utilization of international medical graduates?


The results show that there is indeed a shortage of physicians. The population size and age are growing faster than physician supply. In 2005, in Ontario alone, approximately 1.2 million Ontario residents were unable to find a family doctor and the physician shortage now exceeds 2100 doctors (Esmail, 1). Canada had fewer physicians per capita in 2003 than most developed nations who have universal access healthcare insurance programmes (Esmail, 1). Canada’s physician-to-population ratio was increasing from the 1960s until the 1980s and hit its peak in 1993 at 2.2 physicians per one thousand people. Today, largely due to the 1991 Barer-Stoddart Report, Canada’s physician-to-population ratio is below what most nations provide to their citizens. Furthermore, the forecasted physician-to-population ratio for 2015 is 1.5 physicians per one thousand people, well below the minimal need of 1.9/1000. The results suggest that there is a shortage of supply of physicians due to four main issues: 1) the policy changes to decrease medical school admissions in the mid 1990s. 2) The restrictions of International Medical Graduates in the 1990s. 3).The reduced workload expected of physicians (an aging physician population, higher female/male ratio in the profession, changing work expectations), and 4) increased demand through immigration, an aging population and increasing life expectancy. It is recommended that new policies need to be implemented. Those policies need to be more realistic and proactive and place the health of Canadians at the top of its priorities. We need to train more doctors, accept more qualified, foreign trained doctors as well as retain our own physicians from leaving the country. In parallel we need to rethink healthcare model and implement as broadly as possible the Interdisciplinary Collaborative Practice (IDCP) model that promises reduced costs, increased collaboration between healthcare professionals and improved quality of care.

Lessons learned:

The lessons learned are that many decisions made in the past have been made hastily, with no vision of the long term effects. We need to act now to have the appropriate human resources for healthcare system to serve Canadians effectively and efficiently. By placing an emphasis on Human Resources in Healthcare carries the best chance to achieve sustainable success, quality of care and patient satisfaction throughout the country.

Health Financing Options for Himachal Pradesh: Agenda for Health Policy Reforms

Author(s): R. N. Batta1
Affiliation(s): 1Special Secretary Planning, Government of Himachal Pradesh, Shimla, India
Keywords: Health policy; health financing; social health insurance

Health services in Himachal Pradesh are largely in the public domain with government being the key provider of health services. Even though the state has excellent record in terms of some health indicators, there are serious concerns of access, equity, and quality of service. In the absence of health insurance, people living below the poverty line meet their healthcare needs through direct out-of-pocket expenditure. Things are much worse in remote and hilly regions where neither government nor private facilities are available. Where accessibility is not a constraint, the primary health centres are generally found to be dysfunctional or providers of low quality services.


This paper aims at (a) evaluating the current health policy regime and finding out its effectiveness to handle healthcare issues (b) finding out alternate health financing options and their relevance for Himachal Pradesh (c) the current gaps in human resource availability and the possible public private partnership options to meet the gaps. Primary data on use of health facilities at selected rural and urban health centres is collected from the records maintained at the health centres. For information on position of Himachal Pradesh with regard to selected health indicators, report of the National Family Health Survey (NFH3) 2005-06 is used. The availability of resources at the Primary Health Centre (PHC) level is examined by conducting interviews of the health functionaries at urban centres and remote localities. A thorough review of literature on health studies in the state and other parts of the country, the experience of various states in India on alternate options of health financing, and examination of possible public private partnership options helped in firming up recommendations for policy changes.


Major findings of the study are: (1) There is a serious problem of public under funding of healthcare. As a result, even though health services are supposed to be available free, people have to pay for purchase of medicine and diagnostic services. There are concerns in terms of equity of access. With tertiary healthcare consuming 70% of resources and being used mostly by rich people, civil servants and the formal sector workers; poor are deprived of even the primary healthcare services. (2) While all positions in urban health centres are filled up, more than 50% of health centres in rural areas are without doctors and technicians. Besides, there is a serious problem of mismatch of health professionals and diagnostic hardware. While 42% centres have hardware facilities without technicians, 30% centres have technicians without diagnostic facilities. Even urban centres have problems in meeting recurring expenses making the availability of services erratic. (3) Attempts to mobilize funds through the introduction of user charges though showed initial good results, however, in the absence of adequate participatory arrangement in management of funds, absence of transparency in expenditure and inability to tap the willingness to pay, resulted in withdrawal of the policy. (4) Health policy has no provision to attract private investment in the healthcare and health education. The policy of offering free tertiary care services even to the rich and those having capacity to pay presents a strong disincentive for the private investors. Policy of providing unlimited payments for OPD and inpatient services to the civil servants in public and private hospitals has created serious problems of moral hazard.

Lessons learned:

Since health services cannot survive and deliver efficiently unless appropriate cost recovery mechanisms are in place, health policy has to aim at developing suitable environment that enables cost recovery while simultaneously protecting the poor through tax funded social health insurance. Such a policy could promote public private participation in health provision thus filling the gap due to shortage of government resources.