Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Making It Better: NZ GPs Improving Access to Elective Services and Bridging the Primary/Secondary Gap

Author(s): R. S. J. Gellatly*1, R. Naden1, c. Perry1, J. Palmer1
Affiliation(s): 1Elective Service team, Ministry of Health, Wellington, New Zealand
Keywords: GPs (general practitioners), primary/secondary interface, GP Liaisons, elective services
Background:

Ministry of Health committed to improving elective services waiting times from 1999.The idea of using GP Liaisons (GPs who liaise) to assist this work came from an article in the BMJ. Since the inception of the role, changes in the NZ health system such as District Health Boards being responsible for regional health needs (rather than a focus on hospital services only) and the implementation of the primary healthcare strategy require better communication across that interface.GPLs now have a broad range of activities in improving the patient journey across the primary/secondary interface.

Summary/Objectives:

The range of roles and activities of GPLs around the country will be described, in relation to various sized district health boards in urban and rural New Zealand. Examples of improvements in which GPLs have been involved will be detailed, such as triaging referrals, changing pathways to improve patient access, providing a primary care perspective in hospital settings. Opportunities for further collaboration and innovation will be highlighted.

Results:

Elective service access has been improved. One of the factors in this has been GP Liaisons. As hospital-based consultants and administration staff gain confidence working with GPLs, other areas for improvement are identified. These vary with the local areas needs. Primary care benefits from having a voice in the hospital and a recognised conduit for issues and ideas to be raised.

Lessons learned:

Building relationships based on improved outcomes has opened up communication across the primary/secondary interface. GPs have a combination of practical can-do attitude, experience of working in both primary and secondary care, and the ability to see the big picture in the complex system that is healthcare delivery. Supporting the GPL network is important for its success. GPLs use many tools gleaned from leaders in health. Having paid time in the day is also a success factor.

New Ways to Achieve Primary Healthcare in India: A Critical Review of National Rural Health Mission

Author(s): K. R. Nayar*1
Affiliation(s): 1Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Keywords: Primary healthcare, health services system, India
Background:

The idea of a health ‘worker’ from the community is not a new one; from a public health point of view, it may be an ideal vehicle for another development in the field. But it failed miserably in the case of the Community Health Guide/Volunteer (CHV) scheme due to several reasons. The most serious problem with the CHV scheme was the selection process; it was misused to distribute political patronage and even close relatives of panchayat leaders were selected. The training was extremely limited but in the course of time, most of the CHVs became quacks. A programme meant to give ‘people’s health in people’s hands’ ended up as mere quackery. It is against this background that the government introduced the National Rural Health Mission (NRHM) which includes a women’s community health volunteer called Accredited Social Health Activist (ASHA).

Summary/Objectives:

This paper critically reviews the National Rural Health Mission from a public health perspective as well as based on the ideals of Primary Health Care (PHC).

Results:

The key strategies of the Rural Health Mission include: ensuring intra- and inter-sectoral convergence, strengthening public health infrastructure, increasing community ownership, creating a village level cadre of health workers, fostering public-private partnerships, emphasizing quality services and enhanced programme management inputs.. Community participation will be enhanced by giving functional responsibilities and powers to the panchayati raj (local self-government) institutions, apart from creating a cadre of voluntary accredited social health activists, and a drug and contraceptive depot at the village. The mission will also use management experts, Chartered Accountants, Business management specialists and GIS specialists for its management units.
We find that the utter neglect of primary care and primary healthcare institutions has influenced the utilization of health services and contributed to the worsening epidemiological profile in the country in recent years. In the present form, the proposed mission adds to the confusion about the approach to healthcare in the country. Cost-effective interventions such as the rational distribution of financial and medical resources, including drugs, effective manpower distribution and primary healthcare approaches, should be part of the vision.

Lessons learned:

This paper recommends that a vision that gives primacy or rather credibility to the vast network of health institutions that the country has built over years is needed. Strengthening the sub-centres and equipping the government’s own health workers (instead of adding posts) would be epidemiologically and economically more effective. States should be allowed to define their own priorities and plan programmes. At present the public health scenario is extremely nebulous and the differential pattern across states is so glaring that it does not allow the imposition of pan-Indian solutions.  Apart from this, there is also a need to equip and enable elected representatives at the village and block level for handling health issues. Presently, health programmes are beyond the reach of people who are supposed to govern under the decentralised form of government as these are often considered technical subjects. There is a need to remove the confusion among representatives and officials at the panchayat (local self-government) level about the roles and responsibilities around health services. This paper concludes that initiatives such as the rural health mission would greatly benefit if it follows the vision of those that scripted India’s health service system based on an integrated and unified approach as against the selective interventions being proposed in recent years.

A Model for the Integration of Primary Healthcare Services in KwaZulu-Natal, South Africa

Author(s): M. N. Sibiya*1
Affiliation(s): 1Nursing, Child and Youth and Environmental Health, Durban University of Technology, Durban, South Africa
Keywords: Primary healthcare, integration, district health system, South Africa, grounded theory approach
Background:

The redirection of the healthcare system towards Primary Health Care (PHC) along with the concomitant establishment of the District Health System (DHS)as a framework for PHC delivery and management has been the transformation event in the public health sphere in South Africa since 1994. On the other side, this move towards transforming the healthcare system has been met with numerous impediments, flaws and failures, many of which have not yet been mastered, solved or ironed out. As equity and access to healthcare have since 1994 been considered the key principle to steer the transformation of health services in South Africa, a mechanism was required to define parameters for service delivery, as well as to ensure comparability in the rendering of services. This mechanism realized in the form comprehensive PHC service package that was introduced by the National Department of Health in 2001. Whereas in the past in the South Africa, the model of PHC delivery was strongly based on a vertical approach, the PHC package envisages an organization of services that allows for a one-stop approach. The comprehensive PHC service package is aimed at defining services per level of facility as a way to maximize the integration of services. Nevertheless, integration of PHC services continues to be seen as a pivotal strategy towards the achievement of the national goals of transformation of health services, and the attainment of a comprehensive and seamless public health system. The problem, however, arises in the implementation of integrated PHC as there is no agreed upon understanding of what this phenomenon mean in the South African context. To date no re- search studies have been reported on the meaning of the integration of PHC services. Hence, there is a need for shared views on this phenomenon in order to facilitate an effective implementation of this approach.

Summary/Objectives:

The purpose of the study was to analyse the integrated PHC (IPHC) within a DHS in South Africa and thus the shared meaning of the phenomenon. Ultimately the aim is to develop a model for the integration of PHC programmes in KwaZulu-Natal.

Results:

Grounded theory approach was used to guide the research process. Theoretical selection of clinics located within four health districts in KwaZulu-Natal was done. Data were collected by means of observation, interviews and document analysis. The results indicated that the majority of the clinics offered most of the services that are listed on the comprehensive PHC core package although the process of implementing the integration of PHC services was done differently in all the clinics where observations were done. All participants interviewed understood the IPHC services as provision of all services in the clinic as stated in the comprehensive PHC core package. However, they expressed different views regarding the process of provision of these services. From the data sources, it emerged that the need for the integration of PHC services in South Africa arose as a response to health needs of the community, the shortage of staff and limited infrastructure and the fragmentation of PHC services. The results also indicated that IPHC resulted in improved accessibility of services. However, on the contrary the unintended consequences of integration were reported to be overcrowding in the clinics thus resulting in deteriorating quality of patient care.

Lessons learned:

These are the preliminary results of the study. The researcher is still in the process of identifying the emerging categories that she will use in developing a model. Supermarket approach, one stop shop and comprehensive services emerged as conceptual categories for understanding integration of PHC services from the data analysis process. The researcher noted that the interviewees used the terms ‘supermarket approach and one stop shop’ interchangeably.

Re-Establishing Primary Healthcare by Settling Clinical Practitioners in Communities: This is Possible!

Author(s): D. Desplats*1, G. Farnarier2
Affiliation(s): 1Santé Sud, 2Service de Neurophysiologie Clinique, Hôpital Nord - Université de La Méditerranée and Santé Sud, Marseille, France
Keywords: Primary healthcare, medical workforce, community general practitioners, Mali, Madagascar
Background:

The 2006 World Health Report, entitled Working together for health, contains an expert assessment of the current crisis in the global health workforce. The report reveals an estimated shortage of almost 4.3 million health workers worldwide, but also underlines, among others, severe problems e.g. of training, geographic distribution, working conditions, and brain drain.  We emphasize that General Practitioners are particularly concerned by unemployment and brain drain. Primary Health Care (PHC) was aimed at transferring diagnosis and treatment responsibilities to medical personnel other than doctors. The 2000 World Health Report on Health systems: improving performance had already shown that PHC had reached its limits in terms of quality and performance.

Summary/Objectives:

Santé Sud is a French NGO, specialized in sustainable development programmes, based on the capacity building of local health workers. Since 1988 in Mali, and later in Madagascar, Santé Sud has encouraged newly graduated doctors to serve in rural areas, in order to promote quality healthcare at the community level, combining family medicine and community practice.

Results:

In Mali and Madagascar, 166 Community General Practitioners (CGPs) have been integrated into rural communities over the long term, with a private/public partnership; over 1.5 million people now have access to a fully trained Doctor to answer their everyday medical needs.

Lessons learned:

Clinical practice has been neglected, in spite of the increasing number of medical graduates in least developed countries (LDCs). PHC results in symptomatic practices (symptom = treatment), which turn out to be brief, impersonal, based on simplistic schemes and focused on vertical programmes. We give examples of how modern clinical activity can be, as a combination of science, art and ethics. We show how efficient a well-thought clinical diagnostic approach can be, even when procedures are not readily available. We show how satisfied patients can be, thanks to thoughtful and comprehensive management by a trained doctor. PHC used to represent a great hope, but has been subjected to heavy criticism in recent years. We think that it must be re-established by supporting the settling of first-line CGPs trained in community practices. The experience of Santé Sud shows that it is possible to create the conditions of a second-generation PHC managed by doctors.

Comprehensive Assessment and Management of Hypertensive Patients in Primary Healthcare Facilities of Guatemala

Author(s): C. Mendoza Montano*1, P. Orellana2, A. de Arroyo3, M. Ramirez Zea4
Affiliation(s): 1Health Promotion, 2Medicine, 3Epidemiology, Guatemalan Association for the Prevention of Heart Diseases-APRECOR, 4Chronic Diseases, Institute of Nutrition of Central America and Panama CAP, Guatemala, Guatemala
Keywords: Chronic diseases, cardiovascular diseases, risk factors, hypertension, health system interventions.
Background:

In Guatemala, cardiovascular diseases (CVD) are becoming the leading cause of mortality and disability. The rising burden of these diseases makes it imperative to formulate effective community and health system-based interventions. Currently, the primary healthcare (PHC) system in Guatemala is mostly oriented to communicable diseases and maternal/child health so public PHC centres lack adequate programmes to cope with the increasing demand of CVD.

Summary/Objectives:

The objective of the study was to assess the feasibility and effectiveness of a comprehensive CVD risk reduction programme targeting patients with hypertension that could be integrated into the PHC facilities of Guatemala. The programme was designed for assessment, CVD risk stratification and management of adult individuals detected to have hypertension through opportunistic screening. Patients were stratified at low, medium and high risk based on the level of blood pressure and the presence or absence of other simple, non-invasive variables such as age, personal and family history of CVD, waist circumference (WC) and tobacco use. All patients received lifestyle counselling including smoking cessation, promotion of healthy diet and physical activity. Drug therapy with an antihypertensive medication was restricted to patients at high cardiovascular risk.

Results:

A total of 114 patients (54 ± 13 years old, 74% women and 26% men) were enrolled during a 6 months period at the public PHC clinic of the community of Villa Nueva. Seventy patients were followed up with a second visit to the clinic, and 43 with a third visit. Significant reductions were observed during the first follow up (36 ± 18 days later) in the group mean systolic blood pressure (from 164.9 ± 27.7 to 150.0 ± 21.0, p < 0.01 mmHg) and was even higher during the second follow up (168.0 ± 27.0 to 138.1 ± 17.3, p < 0.01). WC did not change during the first follow up (97.1 ± 8.4 to 95.2 ± 8.8cm, p = 0.14); however, a significant reductions were achieved (from 97.1 ± 8.4 to 93.2 ± 6.9, p=0.04) in patients (N=40) who had 3 visits to the clinic (71±20 days later). Of the 13 tobacco users, 7 discontinued use (53%).

Lessons learned:

This pilot study provides preliminary evidence of the effectiveness and feasibility of incorporating a CVD risk reduction programme into the limited healthcare infrastructure of Guatemala and probably applies to other developing countries.

Building Partnership between Mental Health Workers, Social Workers and Medical Professionals to Enhance Capacity for Effective HIV and AIDS Responses in the Western Balkans Region

Author(s): B. Schwethelm*1, L. Hsu1
Affiliation(s): 1Fondation Partnerships in Health, Céligny, Switzerland
Keywords: HIV and AIDS, capacity building, mental health workers, social workers
Background:

The Western Balkans region covers Albania, Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, Serbia and UNMIK Kosovo. The political instability, combined with socio-economic transition and extensive stigma and discrimination against marginal populations heightens the HIV vulnerabilities of these groups. International assistance has previously ignored the region whose health system is now in the process of being reconstructed and modernized. Strengthening the capacities and updating knowledge of health, mental health, and social workers in HIV and AIDS diagnosis, treatment, work place protection while building partnership between the public sector and local NGOs can facilitate reducing stigma and discrimination and improving access to care and support for marginalized populations. Knowledge, attitudes and practice assessments were conducted with primary healthcare doctors and nurses, psychologists, community mental health workers and social workers. The assessments identified the double jeopardy of HIV vulnerabilities combined with mental illnesses facing marginalized populations. This programme responds to this gap by strengthening mental health, social work and infectious diseases services of the health systems in the Western Balkans.

Summary/Objectives:

Improved risk assessments, counselling and referral coordination to strengthen health system support to PLHIV and marginalized populations in HIV prevention, AIDS treatment, care and support

Results:

Needs assessments have been conducted in three countries involving nearly 400 health and 150 social workers in public community healthcare services. Survey results indicated fundamental gaps in HIV knowledge (e.g., modes of transmission, the ‘window period’ of infection, HIV status of the partner of the PLHIV, client rights to confidentiality). For example, few health or social service providers would maintain the client’s right to confidentiality, being particularly willing to share the client’s status with their family. Only a small proportion of these workers had experience with HIV positive clients, and few would feel comfortable in having any contact with an HIV positive client. The size and volume of service also influenced the attitudes of the respondents. While there was substantial interest to learn more about HIV and AIDS, most practitioners gained their knowledge from TV and to a lesser extent, from professional journals. Access to professional conferences and workshops is limited in these countries. A model HIV and mental health support training curriculum has been developed based on the assessment findings. Each country’s curriculum committee is composed of staff of the mental health department, the community social worker’s group, the National AIDS Coordinator and infectious diseases specialists.

Lessons learned:

The strengthened collaboration and coordination between mental health and HIV service providers in the health system, with protection of client confidentiality, could improve access to the healthcare and social services for PLHIV and other marginalized populations, such as trafficked women, commercial sex workers, ethnic populations (Roma and other minority groups), men having sex with men, injecting drug users, and migrant workers.

Prevalence of Long-Term Use and Prescription of Benzodiazepines in Primary Healthcare Patients in Northern Bosnia and Herzegovina

Author(s): N. Perone*1, S. Aebischer Perone2, A. Sredic3, M. Kvaternik4, S. Huseinagic5, B. Broers6
Affiliation(s): 1Division of International and Humanitarian Medicine, University Hospitals of Geneva, Switzerland, 2ICRC, Geneva, Switzerland, 3FaMI Project, Fondacija fami, 4PHI Doboj, Public Health Institution, Doboj, 5PHI, Public Health Zenica, Zenica, Bosnia and Herzegovina, 6Addiction Unit, University Hospitals of Geneva, Switzerland
Keywords: Addiction, benzodiazepines, Bosnia-Herzegovina, primary care
Background:

After the war in Bosnia-Herzegovina (1992-1995), many persons suffered from post-traumatic stress disorder, depression or anxiety and were treated with benzodiazepines. In humanitarian drug distribution after the war, benzodiazepines rated at the third place. Long-term use of benzodiazepine is inefficient and can induce dependence and cognitive problems.

Summary/Objectives:

The objective of our study was to estimate prevalence of benzodiazepine long-term use and their prescription in primary care patients ten years after the war. Doctors and nurses attending a family medicine course in Bosnia-Herzegovina, financed by the Swiss Development and Cooperation Agency, collected data for this cross-sectional study in their clinics between 10 December 2004 and 24 January 2005. They filled a 33-item coded questionnaire administered to 10 consecutive patients older than 16 years consulting the same day.

Results:

709 patients were interviewed. Overall use of benzodiazepines was 34%, highest in the 60-69 years age group (42.8%) and in persons educated less than 5 years (41.4%). 60.5% took diazepam (average daily dosage 5.35 mg) and 22.4% bromazepam (2.75mg). 38% used benzodiazepines < 4 months, 20% between 4 -12 months and 52% > 1 year. Mainly specialists introduced the drug (53.2%, vs 30.5% family doctors vs 16.2% auto-medication). Indications for benzodiazepines were sleeping problems (25.5%), anxiety (23%), and hypertension (13.7%). More than 50% were not ready to stop in the next 6 months, 18.5% were thinking to quit within 6 months and 8% were ready to quit during the next month.

Lessons learned:

Prevalence of benzodiazepine use was high. Although dosages were within therapeutic ranges, half of users took the medication for more than one year, for unrecognised indications or without a formal prescription. Few intended to stop benzodiazepine use at short term. Doctors should be trained in screening and in non-pharmacological interventions for anxiety and sleeping disorders.

Patient Perspectives on Primary Healthcare: Priorities, Planning and Perils

Author(s): S. Regan*1, D. E. Watson2, S. T. Wong3
Affiliation(s): 1PhD Candidate, School of Nursing, University of British Columbia, Vancouver, 2Director of Research and Analysis, Health Council of Canada, Ottawa, 3Assistant Professor, School of Nursing, University of British Columbia, Vancouver, Canada
Keywords: Primary healthcare, patient perspectives, health human resources
Background:

Patient perspectives on primary healthcare (PHC) reform have substantive implications for planning, organizing and delivering health human resources, since healthcare systems should be designed to align with and be responsive to population health needs. Increasingly, healthcare decision-makers in Canada and around the world are actively seeking public involvement in health policy decisions regarding healthcare renewal.

Summary/Objectives:

The objectives of this study were to examine patient perspectives on PHC to inform quality improvement and performance measurement initiatives. Specifically we wanted to understand 1) features of PHC that are considered priorities by patients; 2) factors identified as relevant to needs-based planning for health human resources; and 3) examine geographical differences in perspectives. Seventy-five people were recruited to participate in 11 focus groups held in multiple sites across British Columbia, Canada. The locations of groups were selected to ensure variation in population size, geographical location, population health status, and expenditures on PHC services. Participants were asked about the features of care that were important to them when making an appointment and visiting primary healthcare providers. Participants were asked about ways in which PHC could be improved. Focus groups were taped and transcribed. Content analysis included inductive and deductive methods.

Results:

Sixty-five per cent of participants were female, more than half (62%) were 50 years or older. Most participants (96%) had a regular provider and had been with that provider for a mean of 8.5 years. Features of PHC considered priorities by patients included six global dimensions: 1) accessibility (geographic accessibility to and timeliness of services), 2) continuity (informational, relational and management), 3) responsiveness, 4) interpersonal communication, 5) technical quality, and 6) whole-person care. Focus group participants specifically identified their changing healthcare needs with an increase focus on chronic care management as a factor relevant to health human resources. Participants discussed some challenges in accessing or obtaining care due to a perceived inadequate supply of PHC providers (primarily physicians). They discussed a desire for change in how they obtained PHC and specifically their openness to have other healthcare providers provide PHC in addition to physicians.
Finally, participants in small communities described how their geographical location contributed challenges to timely access to a regular healthcare provider and continuity of information and management of people’s chronic disease conditions. They suggested that the perils of travel to larger communities to access care, especially in winter months, lead to ‘trade-offs’ between their safety and accessing the needed care. Access to other healthcare services including specialist physicians and diagnostic tests pose additional challenges for those living in small communities contributing to a multiplicative effect of barriers to access and continuity.

Lessons learned:

Patients have much to contribute to health policy and direction for healthcare reform. They have an intimate knowledge of what works well and what doesn’t regarding their access to and utilization of PHC and other healthcare services. Patients make trade-offs to access care. However, they articulate solutions and strategies for improvement that are consistent with many policy objectives and in so doing, they convey their expectation for change.

Why Doctors Strike in Public Health Systems in India: Lessons for Medical Education and Addressing Migration of Healthcare Workforce

Author(s): A. Das1
Affiliation(s): 1Director, Centre for Health and Social Justice, New Delhi, India
Keywords: Medical ethics, health systems, workers rights, training, medical education, health policy, India
Background:

India is emerging as a global economic superpower but lags behind many nations in health related MDG indicators. India has a severe shortage of doctors in the public sector and huge public healthcare crisis. The new public health policy in India, the National Rural Health Mission promises an improvement in the public health system and in improvement in basic public health indicators. It is based on the principles of comprehensive primary healthcare. There have been a large number of strikes by young doctors and doctors in training in India over the last couple of years. These have taken place in tertiary teaching hospitals and across many states. The reasons have varied but there are strong links to young doctors wanting privileges and personal opportunities. These include refusal to undergo compulsory rural or public sector posting, or seeking opportunities to go abroad.

Summary/Objectives:

The paper is based on newspaper and other secondary reports of a range of strikes across various states in India over the period of the last three years since the National Rural Health Mission was announced. The reasons given for the strikes by young doctors or doctors in trainings, as well as the provocations are examined. The response from the health bureaucracy is examined in the context of the national constitution and health policy guidelines.

Results:

The paper provides a short historical summary of the growth of western medical training in the country over the last one hundred and fifty years. The paper examines the changing context of western medicine in providing healthcare to rural and poor citizens in India and the role of the public and private healthcare sector. The paper examines the strikes by young doctors in the context of the growing private sector medical industry and the phenomenon of ‘medical tourism’ that has come up in the country. The paper also examines the validity of strikes by doctors and doctors in training in the context of medical ethics and worker rights.

Lessons learned:

Medical education needs to be guided by a number of factors. While it is necessary to provide up-to-date medical information, and build adequate clinical skills, it is also essential to ground it in the constitutional character of the country and in medical ethics. Doctors are not technical agents in a market place selling healthcare innovations but agents responding to the social and political reality relating to health in the country in which they are trained. The application of these principles in designing medical education curriculum may prevent widespread migration of medical personnel from developing countries.

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
Background:

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.

Summary/Objectives:

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.

Results:

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.