Strengthening Collaborative Health Systems Research and Capacity Building in India

Strengthening health systems is key to securing good health for all people. Health systems are complex, comprising diverse actors who work in silos yet are loosely interconnected. The rapidly evolving area of health systems research has shown the impact of evidence-backed policy actions on population health outcomes. Over the years, India has seen various collaborative learning platforms involving government, development partners, the private sector and civil society organisations.

The need to develop health systems capacity, particularly at the state- and district level, became a critical plan after the National Rural Health Mission (NRHM) initiation in 2005. NRHM strategies focussed on developing Programme Implementation Plans (PIPs) at the district and state level, which required handholding and capacity building of the health system actors. Hence, the Ministry of Health and Family Welfare (MoHFW) set up the National Health Systems Resource Centre (NHSRC) under the framework of the NRHM with the objective of strategic planning and development of health sector reforms in the country. The NHSRC was instrumental in providing collaborative training for developing district and state health plans with the support of state health departments and NGOs. The Public Health Resource Network (PHRN), a civil society initiative, partnered with the NHSRC to mobilise resource persons all over India for regional and state workshops across many states. The training helped in developing the capacity of the public health cadre in all tiers of the public health system and improving the planning processes under the NRHM. Later, this mandate was expanded to establish state health systems resource centres (SHSRCs) in many states.

Along with the rollout of the NRHM, the Government of India also implemented the Rashtriya Swasthya Bima Yojana (RSBY), a health insurance scheme, for informal sector workers. Many state governments also initiated state health insurance schemes such as Rajeev Arogyasri in Andhra Pradesh, Vajpayee Arogyasree in Karnataka and Chief Minister’s Comprehensive Health Insurance Scheme in Tamilnadu. But there was limited capacity and technical expertise at the state level, especially on monitoring health insurance schemes, benefits package design, costing of packages, fraud control and data analytics. The joint learning network (JLN) for the universal health coverage platform, funded by the Rockefeller Foundation and anchored by the ACCESS Health India (AHI), facilitated learning opportunities in all these areas at the federal and state level. The JLN platform included 27 member countries, and India was also a member of the learning collaborative for implementing health systems reforms while learning the technical and practical aspects of implementing and improving universal health coverage. Under this learning collaborative, technical resources from states implementing various health insurance schemes were trained in costing, benefits package development, fraud control, medical audits, data analytics and primary care reforms.

The World Bank launched another important learning collaborative in 2011, known as the Government-Sponsored Health Insurance Forum in India. This initiative brought together policymakers and practitioners from across India and international technical experts to discuss various implementation issues in India’s publicly financed health insurance programmes. The forum was hosted with the MoHFW and facilitated more than 12 workshops in various thematic areas of health insurance implementation. The Government Sponsored Health Insurance Schemes (GSHIS) forum helped in knowledge exchange and debates among the different health insurance programmes within the country and helped assimilate cross-country experiences.

The Public Health Foundation of India (PHFI), Indian Institute of Public Health (IIPH) and Indian Institute of Health Management and Research (IIHMR) are good examples of academic institutions offering a wide range of learning opportunities, especially for health human resources, working in government and private sectors. These offline and online programmes aim to develop the skillsets in health systems research, implementation research, health management, health communication, health care quality and monitoring and evaluation. These learning programmes are customised to the needs of the participants and are interdisciplinary. Many programmes are co-hosted with the support of the state governments and state departments of health and family welfare. Administrative Staff College (ASCI), Hyderabad; Institute of Public Health (IPH), Bangalore; and Faculty of Management Studies (FMS), University of Delhi, are examples of learning collaboratives in various domains of health systems research. The FMS has been a pioneer in providing management education in the health sector.

The areas of health informatics and health insurance are critical given the launch of flagship programmes like the Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PMJAY) and the more recently announced Ayushman Bharat Digital Mission. Ayushman Bharat health reform agenda coupled with the growth of private healthcare, including digital health and the private health insurance industry, makes it vital for readying a cadre of trained healthcare professionals equipped to manage complex health systems. With the implementation of AB PMJAY, efforts are also made to impart technical training and continuous learning support to the staff of state health agencies (SHAs), public and private facility managers and Ayushman Mitras. ASCI, with the help of GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit), has initiated orientation workshops about the PMJAY programme and health insurance in general for SHAs. ASCI is also partnering with the AHI to deliver certificate programmes on health informatics and health insurance. The AHI is also partnering with the Insurance Regulatory Development Authority’s prestigious Institute of Insurance and Risk Management to jointly conduct capacity-building programmes in health insurance and co-develop research in health systems.

The COVID-19 pandemic was a recent example demonstrating the power of collaboration, and the evolution of the India Health Systems Collaborative (IHSC) is the best example. In a short span, the network organically grew from 11 academicians to 1,600 professionals, including academicians, policymakers and other relevant stakeholders loosely associated with the collaborative. It has conducted 11 research studies on policy-relevant research topics selected in consultation with researchers, practitioners, donor partners and policymakers. The IHSC also launched the mentor-mentee programme in collaboration with NITI Aayog in September 2021, aimed at inculcating systems thinking in young researchers. Another notable initiative is the India Health Policy and Systems Research Fellowship programme launched by the Health Systems Transformation Platform (HSTP). The Global Learning Collaborative (GLC) for health systems resilience, convened by the AHI and supported through seed funding by the Rockefeller Foundation, is a new cross-country network of technical experts, practitioners and health policy actors from both public and private sectors collaborating with a purpose of knowledge co-creation and reciprocal learning towards building strong and resilient health systems to prevent and be prepared for future pandemics and other health crises.

Overall, there have been consistent efforts in developing learning collaboratives and networks in India to facilitate collaborative learning, policy-relevant research, policymaker engagement and capacity building. These efforts are now accelerated with the ongoing health systems reform programmes of Ayushman Bharat and other state-level initiatives. Continuous knowledge support is required to strengthen the competencies of public health professionals, healthcare practitioners, policymakers and national and state-level institutions to build long-term health systems capacities. With these small yet concrete steps towards strengthening the Indian health system, the spirit of collaborative work can contribute much more than what we can individually deliver and support the larger vision of achieving universal health coverage.