The Covid-19 pandemic has laid bare gaping fault lines in health and social systems across the globe. Band-aid solutions will not be enough to bridge these gaps. This is the right time and opportunity for us to think big and think deep.
India has seensomemajor health reforms recently, as recommended by its National Health Policy, 2017. Ayushman Bharat, launched in 2018, is a major program with two important objectives. One, itaims to strengthenprimary health care (PHC) through 150,000 Health & Wellness Clinics. Two, it seeks to extend financial protection for hospital-based care (HBC) to nearly 100 million poor families (~500 million people) through the Pradhan Mantri Jan Arogya Yojana (PM-JAY). The program is aimed at achieving the broader goal of Universal Health Coverage (UHC)so improve access to Quality and Accountable Care. How wellthese programs are implemented will determine if the current fault lines are bridged.
The Government of India has recently announced another major health reform through the launch of theNational Digital Health Mission (NDHM). Information becomes critical in highly fragmented and complex health systems. Information is generated at millions of touch points as a person navigates the system from conception to death. How that information is captured, codified, tagged, anonymized, stored, analyzed and shared will determine how the system is functional and effective. India has demonstrated its capacity in launching similar missions – Aadhar Card based identification, Unified Payment Interface (UPI) towards digital economy, and nation-wide single taxation system through the GST network. Successful implementation of the NDHM is hoped to enable our dysfunctional system to leapfrog to a transformed and well-functioning system.
Human resources for health is the most critical component of any health system. Medical education in India received a major reform boost with the scrapping of a scam-ridden Medical Council of India. Supporting reforms were announced such as the extension of retirement age for faculty and appointment of visiting faculty. There is a proposal to convert district hospitals in teaching hospitals to increase the capacity to educate more people and to strengthen hospital-based care in districts, especially to manage the growing problem of non-communicable diseases. The Parliament has passed legislation to recognize and govern Allied Health Professionals, who have become an important addition to doctors and nurses. While these reforms are in the right direction, India needs many more systems-level reforms to strengthen one of the most critical building blocks of its health system.
Major global reports published recently have brought to light, the prevalence of preventable deaths despite the expansion of financial protection. This is largely being attributed to poor quality services. While India has been focusing on improving access to healthcare and providing financial protection, there is an urgent need to bring Quality of Care onto the high table of policy agenda. In addition, inefficiencies in the system (unspent budgets, inappropriate use of diagnostics and therapeutics) account for 20 to 40 percent of wasted resources. While institutional deliveries have increased impressively due to concerted efforts, maternal and infant mortality continues to be high in many states owing to poor quality of care in these institutions. Unnecessary caesarian sections and hysterectomies have become major public health concerns across the country.
Public health is the central piece of any health system. While the healthcare delivery system, mostly primary healthcare and homebased care, is tailored for individual health, public health is designed for population health. It operates where health systems meet other social systems and its interaction is essential in altering social determinants of health such as socioeconomic status, literacy, employment, gender equality, healthy diet and fitness, safe roads, clean air and water. Effective disease surveillance, prevention, and control at population level are crucial functions of the public health system. Metrics on reproductive health reflect the performance of the public health system. Public health should engage people actively in all its activities. For this, constant, clear, and transparent communication is vital. Preparedness against growing epidemics, natural disasters, climate change events, and mass migrations of people is essential to build resilience in the system.
Good governance becomes critical for complex health systems to be effective. How policies evolve and are implemented, how the system performance is monitored, how the system is financed, and how it is regulated constitute the essence of governance. People, providers, payers, and policymakers are some of the important actors in governance. Governments have the onus to provide leadership and stewardship to steer the system as it adapts to multiple forces within and outside of the system. Building individual and institutional capacity towards good governance, such as grooming health systems management cadre, training and development of in-service administrators, and creating opportunities to learn best practices from peers go a long way in strengthening health systems.
In summary, it is evident that we need to adopt “systems thinking” to be able to strengthen complex health systems. Well thought out strategies designed through situation analysis, stakeholder engagement, and policy research along with detailed implementation plans and evaluation systems are essential.