India is often represented as an over-regulated economy. Yet government has played a very limited role in the social services and in healthcare in particular. Research by a consortium of five UK institutions* co-ordinated by the International Development Department in the School of Public Policy, University of Birmingham, explored the changing role of government in the health sector in Tamil Nadu. The study report concludes that despite the lack of an overarching policy framework, the pace of change in the Tamil Nadu health care sector was rapid. Further reform should strengthen, not limit, the future role of government.

Partly because of its sheer size India's healthcare system is very complex. Whilst government policy assigns a significant role to the public sector, government has actually played a very limited part in financing, service provision and regulation of health services. The private sector hosts some 73 percent of qualified physicians and 57 percent of hospitals. In addition, payment is often required for entry to 'free' government healthcare facilities. Services appear to be provided more efficiently if contracted out but the absence of reliable regulatory checks means that standards and quality of care remain patchy in private facilities.

Reform of India's healthcare system will have to work its way through several layers of government. State governments control the bulk of resources going to health and are also allowed much discretion as to whether or not to adopt central policies. In Tamil Nadu the administration has forged ahead with reform in three areas:

• Contracting-out of health services previously provided by the state to private organisations is now fairly common, though the total value of activities contracted-out is small.
• Regulation of the private sector has been strengthened by new laws, but their implementation has faced substantial obstacles and the system is still not effective.
• 'Autonomous organisations' have been founded, receiving substantial government support and performing tasks previously undertaken by government, but functioning in fact as private entities. The Tamil Nadu Medical Stores Company is a case in point. They show signs of performing well but are still dominated by civil servants and do not appear to be accountable to their customers.

The research report concludes that further reforms should be designed proactively to strengthen the role of government in healthcare and to enhance its credibility. Other conclusions of note to policymakers were that:

• The credibility of Tamil Nadu's government among the public is low, mainly due to the poor quality of official health services and widespread corruption.
• Lack of skills among officials of the kind needed to make reforms stick was not found to be a constraint.
• Lack of flexibility in, and control over the terms and conditions of the health workforce limit the government's capacity to perform new roles.
• Officials at state level lack strategic vision and tend to tackle reforms in a piecemeal fashion.
• Some reforms aim to bypassing government rather than achieving reform of government systems. This short-termism is due to the short lifespan of most state governments in an unstable political environment.
• There is conspicuous lack of accountability at all levels. For example local level health workers tend not to feel responsible to the communities they serve, but rather to remote authorities at state level.

Source(s):
Reforming the Role of Government in Tamil Nadu Health Sector, paper 28, School of Public Policy, University of Birmingham, by S. Bennett and V.R. Muraleedharan, 1998 Full document.

Funded by: UK Department for International Development 1996-1998

id21 Research Highlight: 25 February 2000

Further Information:
Sara Bennett
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 0 171 636 8636
Fax: +44 0 171 436 5389
Contact the contributor: sbennett@access.sanet.ge or sara.bennett@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
Search Eldis for sources on health sector reform