Adjunct Faculty, JIPMER International School of Public Health, Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India.
Indian J Public Health. 2021 Oct-Dec;65(4):332-339. doi: 10.4103/ijph.ijph_1951_21.
The debate around approaches to health sector reform is one of the foundational questions around which the discipline of health policy and systems research has grown. In the immediate postwar period, health and health care were recognized as areas of market failure, requiring state action in the provision of free or subsidized services. In the eighties and nineties, due to both geopolitical and ideological reasons, this understanding changed, leading to a wave of market-based health sector reforms. An academic discourse built around neoliberal economics initiated, shaped, and legitimized these reforms. Faced with worsening health outcomes and costs of care after a decade of such reforms, there was a partial reversal of policy toward improving health sector performance that relied on nonmarket solutions built around notions of solidarity, trust, and rights. In India, this took the form of the National Rural Health Mission. Examples of health systems research that supported this direction of change are discussed. In the last decade, a second wave of health sector reforms sought to make markets work by repositioning government as purchaser of health care from private providers through insurance and contracts. There is little evidence that this worked. The need to rely on public services to cope with the COVID-19 pandemic, further questioned this direction of reform. We emphasize the need to expand and develop a framework of health systems and policy studies that are more appropriate to the achievement of universal health care, health equity, and health rights in the Indian context.
围绕卫生部门改革方法的争论是卫生政策和体系研究这一学科发展的基础问题之一。在战后初期，人们认识到健康和医疗保健是市场失灵的领域，需要国家采取行动提供免费或补贴服务。在 80 年代和 90 年代，由于地缘政治和意识形态的原因，这种理解发生了变化，导致了一波以市场为基础的卫生部门改革。围绕新自由主义经济学建立的学术话语发起、塑造和使这些改革合法化。经过十年的此类改革，医疗保健结果恶化且成本增加，随后政策出现了部分逆转，转而依赖基于团结、信任和权利观念的非市场解决方案来改善卫生部门绩效。在印度，这采取了国家农村卫生使命的形式。讨论了支持这一改革方向的卫生系统研究的例子。在过去十年中，第二轮卫生部门改革试图通过通过保险和合同将政府重新定位为私人医疗保健提供者的购买者，以使市场发挥作用。几乎没有证据表明这奏效了。在应对 COVID-19 大流行时需要依靠公共服务，这进一步质疑了这一改革方向。我们强调需要扩大和发展卫生系统和政策研究框架，使其更适合在印度实现全民健康覆盖、健康公平和健康权利。
