India has traditionally had a bureaucratic approach to regulating its health service. Research suggests that this approach has failed to protect the interests of poor and vulnerable groups and has not gained the trust of providers or the public. So are there any other ways to make India's health systems more accountable? Researchers from Johns Hopkins Bloomberg School of Public Health, in the US, and the Indian Institute of Technology, in Chennai, review alternative approaches to regulating health services in India. The bureaucratic approach, with the Ministry of health focusing on its role as inspectorate and provider, has not worked, despite the presence of rules and procedures. Public safety in the health sector is not assured, service delivery and financing are not transparent or accountable, and the delivery of healthcare favours the better-off over the poor. Health providers are viewed with mistrust by the public and have high rates of absenteeism. They often fail to disclose information, particularly on what matters most in the processes and outcomes of healthcare. Above all, India's regulatory approach does not appear to address the reality of unregulated markets, with most transactions in healthcare in India taking place in the private sector to which the government pays little attention. The findings show that new approaches to regulation have emerged in recent years. Notably consumer-based approaches through the 1986 Consumer Protection Act and 2005 Right to Information Act, which aimed to give consumers greater choice of health provider and move the handling of complaints and disputes away from civil courts to Consumer Forums. However, these forums have had difficulties with insufficient staff, poor infrastructure, and limited ability to bring parties to court. Other approaches include: self-regulation through professional associations organised by health providers contracting for health services between governments and non-state providers institutionalised co-production (collaborative approaches where public service regulation is shared through a regular long-term relationship between the state and organised groups of citizens). The researchers conclude that simply creating and enforcing rules will have limited effect. They suggest building on the collaborative approaches that are emerging. However, greater accountability will only happen if governments improve access to information about health sector performance. The Government does not need to measure, analyze or disclose the information itself, it needs to create an environment where such information is seen as necessary by providers as well as service users. Conclusions include the following. The Indian Ministry of Health should improve the effectiveness of citizens' groups by increasing their access to information on the performance of clinics and hospitals, and encouraging them to educate consumers about their rights. Citizens' groups, the media, and provider organisations should play a more active part in disclosing and using information on the performance of both public and private providers. Any attempt to enhancing professional self-regulation should address problems of low consumer trust in providers and regulatory agencies. Contracts with health providers should be made on the basis of performance, transparency, and involvement in quality assurance programmes, or be a condition of participation in the growing health insurance market. More research is needed on ways to demonstrate quality of care, involve the poor in their own healthcare, and indentify factors that build trust in the health system.
Social Science and Medicine (2008) 66 (10) 2133-2144 [http://dx.doi.org/doi:10.1016/j.socscimed.2008.01.037 ] Special issue: Future Health Systems (Eds Bloom, G.; Standing, H.)