Peters David H, Rao K Sujatha, Fryatt Robert
Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore 21205, USA.
Health Policy Plan. 2003 Sep;18(3):249-60. doi: 10.1093/heapol/czg031.
India's health system was designed in a different era, when expectations of the public and private sectors were quite different. India's population is also undergoing transitions in the demographic, epidemiologic and social aspects of health. Disparities in life expectancy, disease, access to health care and protection from financial risks have increased. These factors are challenging the health system to respond in new ways. The old approach to national health policies and programmes is increasingly inappropriate. By analyzing inter- and intra-state differences in contexts and processes, we argue that the content of national health policy needs to be more diverse and accommodating to specific states and districts. More 'splitting' of India's health policy at the state level would better address their health problems, and would open the way to innovation and local accountability. States further along the health transition would be able to develop policies to deal with the emerging epidemic of non-communicable diseases and more appropriate health financing systems. States early in the transition would need to focus on improving the quality and access of essential public health services, and empowering communities to take more ownership. Better 'lumping' of policy issues at the central level is also needed, but not in ways that have been done in the past. The central government needs to focus on overcoming the large inequalities in health outcomes across India, tackle growing challenges to health such as the HIV epidemic, and provide the much needed leadership on systemic issues such as the development of systems for quality assurance and regulation of the private sector. It also needs to support and facilitate states and districts to develop critical capacities rather than directly manage programmes. As India develops a more diverse set of state health policies, there will be more opportunities to learn what works in different policy environments.
印度的卫生系统是在一个不同的时代设计的，当时公共部门和私营部门的期望截然不同。印度的人口在健康的人口统计学、流行病学和社会方面也正在经历转变。预期寿命、疾病、获得医疗保健的机会以及防范经济风险方面的差距都在加大。这些因素正促使卫生系统以新的方式做出应对。以往制定国家卫生政策和计划的方法越来越不合适。通过分析各邦之间以及邦内不同背景和过程中的差异，我们认为国家卫生政策的内容需要更加多样化，以适应特定的邦和地区。在邦一级对印度的卫生政策进行更多的“细分”，将能更好地解决各邦的卫生问题，并为创新和地方问责制开辟道路。处于卫生转型更深入阶段的邦将能够制定政策来应对非传染性疾病的新流行以及更合适的卫生筹资体系。处于转型初期的邦则需要专注于提高基本公共卫生服务的质量和可及性，并使社区有更多自主权。在中央层面也需要更好地“整合”政策问题，但不能采用过去的方式。中央政府需要专注于克服印度各地在卫生成果方面的巨大不平等，应对诸如艾滋病毒流行等日益严峻的卫生挑战，并在质量保证体系和私营部门监管等系统性问题上发挥急需的领导作用。它还需要支持并促进各邦和地区发展关键能力，而不是直接管理各项计划。随着印度制定出更加多样化的邦卫生政策，将有更多机会了解在不同政策环境中行之有效的做法。
