Mulling about the learnings from the COVID-19 pandemic, Dr P R Sodani, Health Economist and Public Health Specialist and currently Pro-President of IIHMR University, Jaipur believes that to develop a resilient health system, India needs to learn from experiences, feed back into policy cycle, support governance and socioeconomic contexts, synergise sectors and actors, promoting dialogue and collaboration between public and private sectors, with effective government supervision.
Health systems have contributed enormously to better health and influenced the lives and well-being of people around the world, but their contribution could be greater, especially for the marginalised and disadvantaged people.
What is a health system? The World Health Organisation definition is, “A health system consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health.” Health system is the means to deliver health policy goals by attaining three fundamental objectives: a) improving the health of the population; b) responding to people’s expectations; and c) providing financial protection against the costs of ill-health.
To achieve these, a health system has to carry out four basic functions: delivering personal and population-based services; raising, pooling and allocating the revenues to purchase those services; creating resources by investing in people, buildings, equipment, drugs, and supplies; and acting as the overall stewards of the resources, powers and expectations entrusted to them.
It is important to note that the linkages between the functions of a health system that impacts the (reinforcing or undermining) interaction between function-specific health policies and strategies. Therefore, synergies determine the coverage of those who need health services, the quality of these services and the efficiency with which resources are used in their delivery.
For strengthening health systems, the functions have been further broken down into a set of six essential ‘building blocks’, popularly known as WHO’s Health System Framework: a) service delivery; b) health workforce; c) information; d) medical products, vaccines and technologies; e) financing; and f) leadership and governance (stewardship).
These alone do not constitute a system but the multiple relationships and interactions among the blocks – how one affects and influences the others and is in turn affected by them – convert these blocks into a system. As such, a health system may be understood through arrangement and interaction of its parts and how they enable the system to achieve the purpose for which it was designed.
Assessing the Indian scenario
With its billion-plus population and less-than-equitable access to healthcare, India has the responsibility to utilise these building blocks to transform its health system, especially in the wake of the pandemic.
Integrating systems of institutions, enhancing capacity of and interaction between local organisations: Service delivery in health system organises and manages inputs and services to ensure access, quality, safety, and continuity of care for all health conditions, without the limitation of locations or time.
Recent experience of COVID-19 pandemic clearly depicted that in order to build a strong health system in India, and the suggestive guideline is: an integrated systems of primary-secondary and tertiary care institutions; readiness and response capacities at all levels – national/ state/ district; increasing capacity to deal with COVID-19 through test, trace, and treatment; enhancing capacity of local organisations, strengthening interactions between them, and improving institutions that underpin these interaction.
Multiple organisations interact to influence health systems service delivery, including the Ministry of Health and Family Welfare, public and private sector health players, non-health sectors and actors, administrators, non-governmental organisations, and professional associations.
The role of the private sector is very critical as it strongly influences the service delivery of a health system. There is no one-size-fits-all way of maximising synergies between various actors to strengthen health systems because local contexts vary significantly, as we have experiences in times of COVID-19. Models of hospital-based and community-based services should be balanced.
Manage dynamic labour markets to improve the distribution and performance of existing health workforce: India’s health workforce consists broadly of health service providers, nursing professionals, para-medics, management professionals for health and hospital with enormous variation in their level and skill. An efficient health workforce is also available, responsive, and productive.
To achieve this, managing the dynamic labour markets and improve the distribution and performance of existing health workforce is important. The suggestive guidelines for further improvement during the pandemic include: increase trained and skilled workforce in contract tracing, case management; use of tele-medicine and e-health for enhancing the accessibility and availability of various treatments/ interventions and advises to the population at large.
There is a strong need to develop district hospitals as the center of excellence for providing training, technical and professional support to public and private sector institutions in the district – local capacity needs to be strengthened.
Strategic use of information: The generation and strategic use of information on health systems is an integral part of the leadership and governance function. A well-functioning health information system ensures the production, analysis, dissemination and use of reliable and timely health information by decision-makers at different levels of the health system.
The information system shall have the capacity to synthesise information and promote the availability and application of knowledge for better and timely decision-making, instead of routine submission of monthly reports. The recent experience strongly suggests strengthening the health surveillance information system for diseases of public health importance.
Medical products, vaccines and technologies: A well-oiled health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
The recent COVID-19 experience strongly suggests revisiting the Indian Public Health Standards (IPHS) for district hospitals, sub-district hospitals, community health centers, primary health centers and sub-centers – together, these public health institutions are nerve of the public health systems in India, their standards in terms of service delivery, human resources, equipment, supplies, and infrastructure need to be re-visited for the sake of the served.
The guidelines for implementing various national health programs should be re-looked at and revised in response to COVID-19. Similarly, procurement processes, supply, storage and distribution systems policies and guidelines need attention.
Aligning central, state and private financing: A good health financing system raises adequate funds for health to ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them.
There is an urgent need to increase public health spending in India. The National Health Policy, 2017 intends to increase the public health spending by 2.5 per cent of GDP by 2025 from the current 1.3 per cent. India’s health system is clearly underfunded, so the question arises: can we achieve the intended goal of National Health Policy with this speed and effort?
India’s health financing policies should focus more on making the health system resilient, and improving health security, and universal health coverage requires total transformation in our policy thinking, coupled with state governments increase their health budget by more than eight per cent of their state budget.
Apart from increasing public health spending, a strong and viable policy for private sector engagement (PSE) is the need of the hour, as the private sector is a key player in providing health services. The policymakers need to find out and select a fit-for-purpose and -context strategy to engage the private sector as part of India’s response to COVID-19, especially in terms of space, staff, and systems for which the available CSR funds can be leveraged by both central and state governments.
Leadership and governance for a long-term and strategic approach: The leadership and governance is the most complex but critical building block of India’s health system that identifies the role of the government and its relation to other actors whose activities impact health systems.
Overseeing and guiding the private as well as public health system is key to ensure strategic policy frameworks exist and are combined with effective supervision, coalition building, providing appropriate regulations and incentives, attention to system-design, and ensuring accountability. The pandemic depicted that India’s health system requires a clear vision to enhance the standards of health for the population with a long-term strategic approach.
To develop a resilient health system, India needs to learn from experiences, feed back into policy cycle, support governance and socioeconomic contexts, synergise sectors and actors, promoting dialogue and collaboration between public and private sectors, with effective government supervision.
It is the multi-faceted relationships and interactions among the building blocks that build a system. A long-term strategic framework should be developed by the governmental and non-governmental organisations (including the private-for-profit sector) to strengthen health systems – a time to transform India’s health system.