India boasts of a well-designed multi-tiered state-level public healthcare system, including sub-centers, primary health centers, community health centers, area hospitals, district hospitals, and tertiary care referral teaching hospitals, based on the Bhore Committee’s recommendations since Independence. The union health ministry has been responsible for laying down the national health policy, medium to long-term vision, and time-bound missions for specific programs. It is also responsible for monitoring and evaluation of the health status of people, and the performance of various national programs. It is responsible for international coordination in health matters that are transnational – public health emergencies, intellectual property rights, international trade regime for health goods, international labor migration, global health financing, etc. It is responsible for national public health emergencies arising out of epidemics and pandemics, natural disasters, industrial accidents, conflicts, etc. Hence, it becomes essential for institutional mechanisms to ensure efficient and effective coordination between the Center and the States, safe-guarded from political differences between the ruling parties at the Center and in the States.
The union health ministry administers health systems through various departments or agencies. The National Health Mission (NHM) is the nodal body for strengthening both rural and urban primary health care across the country. The National Health Authority (NHA) is responsible for implementing two flagship programs under the Ayushman Bharat Mission, namely the Pradhan Mantri Jan Arogya Yojana (PMJAY) that oversees the implementation of public health insurance to cover hospital-based secondary and tertiary care for ~500 million poor people across the country, and the Ayushman Bharat Digital Mission (ABDM) that is aiming at a standards-based, interoperable national health information system. The National Center for Disease Control (NCDC) is responsible for disease surveillance using an integrated disease surveillance platform (IDSP), alerting public health systems upon recognition of signals for potential public health emergencies, to mount rapid responses to prevent and control these emergencies. It is ably supported by the Indian Council for Medical Research (ICMR) which undertakes epidemiological and medical research through its network of research institutes.
National councils regulate the education of medical, nursing, pharmacy, and dental professionals. The Director General of Health Services (DGHS) oversees the functioning of hospitals run directly under the Central government. The central government is also responsible for various teaching institutes (All India Institutes of Medical Sciences and Postgraduate Institutes) directly under its control. In addition to the above, there are various agencies that deal with vertical disease control programs for HIV, Tuberculosis, Malaria, Polio, non-communicable diseases, etc. State governments, similarly, administer health systems through various departments.
The World Health Assembly (WHA) offers an institutional mechanism for coordination between various member nations. The Ministry of Health is supposed to create institutional mechanisms for coordination between various departments and agencies. However, we do not see well-defined institutional mechanisms for bringing about better coordination between various departments at the Center and the state levels. Many of these tend to work in silos. Health information gathered by various departments is not shared between them leading to duplication of data-gathering efforts, which strains the frontline health workers.
Healthcare provider systems at multiple levels do not have bidirectional referral systems leading to discontinuity in care delivered. There is no institutional mechanism for coordination between Central and State health ministries. Hence, there is an urgent need to bring institutional mechanisms that strengthen coordination between various governmental departments across the country for health systems to be effective even during public health emergencies and make these more resilient to face future health threats.
It is an accepted fact that human health is intricately linked to animal, plant, and planet health. The health status of people is influenced by social, economic, environmental, and commercial determinants. Hence, it becomes essential to have institutional mechanisms for inter-ministerial and inter-sectoral coordination and collaboration to improve the health of all people at all times. Whole-of-governance and whole-of-systems approach to health systems governance has become critical. However, there is a huge gap between conceptualization and operationalization. Hence, the onus of health systems governance shifts to the heads of central and state governments.
Governments are only one limb of the governance triangle. People and the private sector that form the other two limbs are as important as the public sector in good and resilient governance. Coordination between all the actors becomes essential for effective governance of complex health systems. Community engagement and private sector engagement are recognized as one of the core functions of governments. While elected representatives are the primary connection between people and the governments, there are many other forms of formal and informal engagement of communities. Institutional mechanisms for formal engagement of the private sector are currently either non-existent or weak.
Information and communication systems play an important role in integrating highly fragmented health systems and their key actors across various levels. Digital information and communication technology is being put to use across various sectors to drive efficiency, effectiveness, coordination, and collaboration. These have the power to bring transparency and trust between various state and non-state actors. Formal institutional mechanisms in the form of committees, councils, forums, etc., enable coordination through scheduled structured interactions.
Coordination has become a critical element of good governance to manage complex social systems. Information, communication, and relations have become essential cross-cutting functions to bring about better coordination between various stakeholders relevant to strong and resilient health systems. India should address this issue to strengthen its health systems and make them more resilient.
Dr N Krishna Reddy
President, InOrder