Journal of Health Management

Compared to its peers, India has always spent far less on health. This is slowly changing as are the drivers that are forcing some of these changes. Demographical and epidemiological changes have moved the disease burden away from communicable and maternal and childhood diseases to non-communicable diseases. More people are city dwellers and achieving UHC is one of Sustainable Development Goals. To tackle these commitments and shifting demands, in 2017, there was a committed move towards improving primary health care by introducing comprehensive PHC through health and wellness centres. These centres are close to the community and by improving the quality of care given and increasing the range of services that they provide, there should be an increase in access to health. However, much needs to be done to ensure that these centres will provide high quality care to the local populations. Training the healthcare workers needed to staff these HWCs will take time. Keeping the required funding to expand the programme will be challenging in the current fiscal space. There is a need to integrate care and flow of funds between primary and secondary care and empowering local populations to engage in governance of the HWCs will take time.

The majority of developing countries in Asia have been making reforms to their health systems for decades but have still failed to achieve their targets for universal health coverage (UHC), that is, ensuring that all people obtain the health services they need without suffering financial hardship when paying for them, and the health- and poverty-related Sustainable Development Goals (SDGs). Countries in Asia rely on a mixture of healthcare financing sources, such as government general revenue, social health insurance (SHI), external funding, private health insurance and out-of-pocket (OOP) payments. Asian countries generally spend between 1% and 10% of their national GDP on health. There are variations in government investment in health as a proportion of total health expenditure across countries, from 23.4% in Japan to Myanmar’s 4.8%. Many governments in Asia have introduced various types of publicly financed health insurance schemes (SHI). The private sector, in providing healthcare, has expanded rapidly, because many national health systems are not able to cope with rising costs, especially for co-payment, and the increasing demand for services. The introduction of private health insurance has reduced OOP payments and, in the long run, could evolve a broader SHI system. As a result of the low levels of government spending, OOP payments by health consumers constitute a large share of health expenditures, amounting to more than US$0.5 trillion or US$80 per capita annually. Rapid increases in development assistance for health (DAH) since 2000 have resulted in major health gains in the poorest countries, yet DAH levels have stagnated in recent years. DAH must evolve to help accelerate progress toward UHC.

In an era where every public health action is expected to be backed by credible evidence, health policy-making has also been increasingly seen to follow the same. The general consensus across the globe is to strengthen health information systems and the decisions of the policy makers are increasingly relying on the information provided to them through such systems. COVID-19 has clearly brought out the need for accurate, timely and relevant information in planning for and responding to public health emergencies that can be equally devastating, if not more. It is crucial for information providers to understand the importance of communicating and disseminating it in a timely manner so that it leads to public health action for the larger good of the population.

Health technologies have been and shall always be an integral part of the health system. Appropriate technologies provide solutions to improve healthcare services at an affordable cost. New biomedical, bioengineering and digital technologies continue to swamp the health system and consume a major part of the health budget. National authorities should develop a policy framework that articulates needs, standards and projections of safe and cost-effective technologies in the context of local epidemiological data and the felt needs of communities. Efficient implementation of health technologies requires availability of an adequate number of skilled human resources for health and infrastructure, for maintenance and replacement or for upgradation of these technologies.

The COVID-19 pandemic caused by a novel virus SARS-CoV-2 has swept the world, leaving behind a trail of free-falling economy, misery and death. The most vulnerable are the hardest hit—the elderly, those with chronic noncommunicable diseases and the poor and marginalised in society. The experience of various countries in handling the pandemic has shown that robustness of health system with surge capacity is critical to take the pandemic head-on. In the process important lessons for health systems have emerged. Countries with political leaders who led with a principled approach, while adopting an early and comprehensive strategy to contain the virus, have done better. Vulnerable populations should not be left to be further marginalised. To deal with the ‘infodemic’, communities should be engaged early. For successful handling of future challenges investment in public health is a must. National readiness and response capacity for epidemic control and disease surveillance need to be strengthened, leveraging modern technology. Institutional capacity building, pooling resources and harnessing innovations through partnerships would be key for mounting effective response now and in the future.

Evidence-informed policy action has improved the health of populations for decades; however, in many contexts, there is limited evidence that it does, mostly because of shortcomings in the process of policy-making. Evidence-based policy-making assists in making decisions about projects and programmes at every stage by using evidence to inform the policy process, rather than directly targeting the objectives of the policy. Although health policy in itself is defined distinctively by experts, it encompasses aspects of ‘public policy in health’ and ‘health in all policies’. By focussing on factors like laws and regulations, and by gaining political commitment for a specific goal, health policies and the resulting programmes can be changed and improved to enhance the health of communities. This process first involves the identification and description of the problem and the evidence-based interventions to solve it. While planning policy, the major actors involved should be identified but all stakeholders should participate in this process. Policy change requires a pragmatic shift in the rules to allow new ways of doing things, deriving programmes with stronger measures, or revising standards for a positive health outcome. These changes involve a very complex process as policymakers need to think of various factors which influence their decision-making, such as evidence of feasibility, stakeholders’ priorities, health impact, socio-political considerations and their effect on the process, and efforts of advocacy groups. A mechanism needs to be developed to evaluate the impact of current policies and every effort should be made to include evidence and research findings in the formulation of new and improved policies, for better health service delivery and to improve the health of the people.

Significance of communication in health and development is well recognised. Strategic communication informs, educates and influences. In addressing varied health and development issues, including the challenges involving diseases control, more targeted communication strategies are designed to make optimum use of available resources to achieve the planned results in a given context. Based on research, that is, the community-based study of risk factors and the operational research, communication theories evolved and so did the strategies and practices for result-driven health and development communication. In this article, some approaches have been examined to better understand the role of strategic communication in development and health, including disease control.

Information dissemination through ‘extension approach’, first for agriculture development and later for family planning, adapted and boosted through advertising and marketing frameworks led to wide awareness about the methods and techniques of family planning but not the adoption at the same levels. Experience and research studies demonstrated that mere ‘awareness’ was not adequate for fostering adoption of ‘new’ practices; instead, it required sustained investments in communication for social and behavioural change processes. For this, bottom-up communication design, participatory communication with community involvement, evidence-based advocacy and preparedness for risk communication are required for effective communication and health and development. As HIV/AIDS posed an initial challenge for communication scholars earlier in the 1980s, so is the COVID-19 pandemic throwing a major communication challenge today. The article attempts to analyse the approaches and shed light on the role of communication in health and development, especially in the context of health crisis.

Population ageing is both an achievement and challenge, an achievement as longevity is the result of successful prevention and control of diseases, decreasing fertility rates and overall socio-economic development. It is at the same time a challenge as the increasing number of older people and the resultant demographic shift are accompanied by the need to adjust and scale up the social and health care systems. The challenges are of particular relevance to the developing world where the demographic shift is occurring much faster.

Comprehensive efforts based on country contexts are required in the following areas: (a) older persons and development, (b) health and well-being and (c) enabling and supportive environments to address population ageing needs. This article, however, focuses only on three most crucial issues, that is, livelihood, health care systems and care of the older dependent people. Measures to sustain the livelihood of older people, to align the health systems to provide care and to develop long-term care systems are highlighted. Person-centred care, integration and functional capacity are advocated. Further, ageing in place or living in one’s own home, community or a place with the closest fit with the person’s needs and preferences is considered very important for healthy ageing.

In terms of enhancing livelihood, major policy changes and reforms to improve the social security systems and expanding coverage as well as increasing the amounts to minimum subsistence levels are highlighted. Another area which needs to be strengthened is the tradition of existing family support systems.

The health systems alignment required are reflected for each health system building block, and focuses mainly on (a) developing and ensuring access to services that provide older-person-centred care; (b) shifting the clinical focus from disease to intrinsic capacity; and (c) developing or reorienting the health workforce to provide care as per alignment.

Long-term care systems would best meet the needs of dependent older people if families, communities, civil society organisations and private sector are equally involved while governments play leadership roles in setting up and monitoring quality.

COVID-19 pandemic has brought to the fore the need for a strong health system for the social protection of people and to improve health programme implementation in the coming years. India has made great progress in health over the past 50 years; however, despite the progress made, it is faced with several challenges. While infectious diseases remain an unfinished agenda, chronic non-communicable diseases (NCDs) are rising and are now the leading cause of mortality in the country. This is further compounded by the prevailing inequalities in access to quality health care among population groups including those living in remote rural areas. To achieve Universal Health Coverage and Sustainable Development Goals by 2030, India in 2017 revised its National Health Policy and committed itself to attain the highest possible level of good health and well-being, through preventive and promotive health interventions. While policies are enunciated and plans are formulated, the implementation at ground level is at best tardy and lack lustre As an administrative unit for programme implementation, a district has a key role to play in implementing national programmes and in delivery of basic health services to the people. They are strategically placed to plan, organise and lead efforts meant to deliver primary health care services through better management of existing resources and by fully engaging all relevant stakeholders in contributing towards achievement of national health goals and in responding to a public health emergency such as Covid-19. Planning and managing health problems need an improved and responsive health governance. Strategic planning, monitoring and evaluation require integration and coordination of various health programmes including dealing with health crises, fostering inter-sectoral involvement and engagement of the community as a key actor. Efforts are needed to ensure that services reach the most vulnerable and marginalised sections of the society. Adequate governance support at district level through a whole-of-society approach is essential to bridge the health inequities and ensure equitable access to health services.

COVID-19 once again has shown the world the importance of an urgent need for revitalising the health system based on a strong primary healthcare foundation. It is clear that without a community-based grassroots level care delivery system, Test, Trace and Isolation may not be an effective operational possibility. Politics of health with consequent austerity programme and dependence on secondary hospital care–based system has proved to be ineffective and costly in meeting the changing demands for healthcare of the population. Demographic and epidemiological transition with the increasing burden of chronic care; unfinished agenda of Millennium Development Goals (MDGs) and the new challenge of achieving Sustainable Development Gaos (SDGs), including Universal Health Care; improving quality along with access to care; and addressing the existing inequity in healthcare service, politicians and public health leaders must realise and invest in people-centred, need-based primary healthcare. Significant and sustained productivity gains can be made through various innovations that can change how quality services are delivered and reduce inequity. In order for primary healthcare to become fit for purpose, it must improve its allocative, technical and service delivery efficiencies; effectiveness and responsiveness of care; access, quality and equity of care; and have an inbuilt monitoring and accountability framework. The system must create a conducive political, social and service delivery environment for innovations. Today, developing countries, as well as developed countries, are all strengthening their primary healthcare system through various innovations to maximise the use of scarce resources to reach all people who need care and minimising cost, wastage and inefficiencies.

The COVID-19 pandemic has thrown into bold relief the need for an all-of-society response supported by regional and global partnerships to control the epidemic. Addressing the social determinants of health, Universal Health Coverage, the non-communicable disease (NCD) burden, the other communicable diseases and the achievement of the Sustainable Development Goals (SDGs) all would require a close collaboration among different sectors and stakeholders, including the private sector.

Partnerships connote three fundamental themes—a relative equality between the partners, mutual commitment to agreed objectives and mutual benefit for the stakeholders involved. The decisions are made jointly, and roles are not only respected but are also backed by legal and moral rights. The World Health Organization (WHO) has been and continues to be the foremost promoter as well as the host for many of the global and regional partnerships in health. A typological classification would include technical assistance partnerships supporting service access and provision of services including drugs, partnerships focusing on research and development, advocacy and resource mobilisation and financing partnerships mainly to provide funds for definite disease programmes.

Partnerships in health have brought and continue to bring multiple benefits to the countries. But they also engender several challenges, including the duplication of effort and waste, high transaction costs (usually to government), issues of accountability and consequent lack of alignment with country priorities.

As partnerships become increasingly significant in the twenty-first century, better coordination, particularly in terms of donor harmonisation with national priorities, would be needed. It is not ambitious to attempt the elusive ideal where all parties will benefit from one other with a give and take between all stakeholders. Partnerships in health could well herald a new dawn for health development in the South-East Asia Region.