Towards a Resilient Post-Pandemic Health System: Lessons through the Spectacles of Indian Health Policy Scenario

Abstract

A resilient health system necessitates strong governance, political commitment, effective administrative entities and inter-organisational collaboration. This paper examines India’s current health policy landscape and explores the analytical and operational capacities required to establish a robust post-pandemic health system using the policy capacity framework described by Wu et al. (2015). We emphasised the need for a coordinated policy response to strengthen health information systems, health service management, human resource management and healthcare financing. The role that the planned implementation of Indian public health management cadres would play in the coming era, the importance of a comprehensive health information management system and the need for operational coordination between government and non-governmental organisations has also been emphasised.

INTRODUCTION

A resilient health system is one that can learn and adapt in the face of major or minor disruptions while maintaining equitable, affordable, and accessible healthcare delivery services. The COVID-19 pandemic acted as such a disruption on countries’ health systems, affecting people of all ages, genders, and socioeconomic groups.[1] On that note, a resilient post-pandemic health system requires a coordinated policy response at all levels of health delivery. This chiefly includes the health information system encompassing research and development, finely orchestrated health services management to maintain quality of care while increasing the service quantity, human resource management and healthcare financing.[1]

This article utilises a policy capacity framework provided by Wu et al. (2015) through a retrospective lens of COVID-19 scenario in India. Existing capacities at different levels of governance have been looked at to assess its capacity to respond to future public health challenges. The rationale in using this framework aligns with the fact that it can serve to strengthen the functioning of health systems in the country along with effectively tackling future public health threats. Analytical capability is defined as the ability to comprehend the nature of an issue and develop appropriate solutions. This includes the ability to collect and analyse data, to conduct research and to develop evidence-based policies. The ability to execute solutions and monitor their efficacy is referred to as operational capability. This includes the ability to develop and implement policies, to manage resources and to track the progress of interventions. The necessity for political will to guarantee that solutions are implemented and sustained is referred to as political capacity. He designed the framework based on the knowledge, abilities and competencies that pertain to the political, operational and analytical capacities existing at three nested levels of governance: the individual level, organisational level and systemic level.[2] We did not discuss political capacity in our manuscript because it was beyond the scope of this discussion, and it warrants future research that takes into account the variability of political landscapes in different countries from a comparative perspective.

ANALYTICAL CAPACITY

Individual analytical capacity in the public health system refers to channelling skilled public health personnel who can not only access grassroot information but also translate it into informed decisions. Following the pandemic, India’s post-pandemic health ecosystem may soon see the entry of public health service cadre in all states/union territories (UTs), as outlined in National Health Systems Resource Centre (NHSRC) and Health Ministry, India policy document 2022.[3] Questions may arise whether implementing a system with such intricate mechanisms will have the capacity to do what is required. A look at the systematic improvement of health indicators in Tamil Nadu can shed light on this. However not a new concept in the Indian ecosystem, Tamil Nadu has had an organised public health system with dedicated cadres in place for a long time, as well as its public health law in place since 1939. With an infant mortality rate (IMR) of 15 (half of the national average of 30) and an MMR of 60, Tamil Nadu has been consistently ranked among the high-performing states in India.[4] Along with Tamil Nadu, several other Indian states have performed admirably in terms of measurable changes in health indices over time. All these point to a developing health system as a result of good governance and political commitment, effective national and subnational administrative entities and collaboration between them. Furthermore, a sustained improvement can be maintained by putting in place qualified, committed public health cadres, innovative service delivery methods and, finally, assuring health system resilience.[5]

Analytical capacity at the organisational level points to a robust health information management system for timely data aggregation and dissemination across various important stakeholders. In India, the Integrated Disease Surveillance Programme (IDSP), which is intended to be at the forefront of disease surveillance and outbreak response, was at a supporting function throughout the pandemic.[6,7] Several deficiencies in human resources, inadequate fund utilisation, a lag time of 8 to 10 days between data collection and submission to the IDSP portal and limited information restricted to case-based aggregates were observed in an evaluation by a joint monitoring mission (JNM) between Health Ministry, India, and World Health Organization (WHO) in 2015–16. JNM reported a staffing shortfall at IDSP in various positions as of December 2015. Epidemiologist (42.1%), microbiologist (32.9%) and entomologist (32.9%) posts were vacant.[8] Though the JNM report dates back almost six years, the situation needs to improve much even now. During the 2018 Nipah outbreak in Kerala, a WHO risk assessment informed the need for specialised public health specialists in IDSP.[6] A similar pattern was observed during the pandemic, when, despite having ample human resources at our disposal, many contractual short-term vacancies of the stated roles had to be established countrywide.[6] All these shortfalls were driven by underfunding; between 2005 and 2018, IDSP’s yearly expenditure was less than its assigned budget in 11 of 13 years.[7] All these point towards the need of a robust integrated disease surveillance system, which is more apt now than ever with the rising consensus towards a one-health surveillance system.

OPERATIONAL CAPACITY

The functionality of the public health system necessitates collaboration between government and non-governmental groups at the operational level. Policy reform including non-governmental organisations’ participation in health in various forms of the public–private partnership must be re-evaluated. Williams et al. (2021)[9] reported that the private sector in lower–middle-income countries has seen a significant loss in revenue due to reduced medical tourism, patients deferring elective surgeries and cost inflation due to the increased requirement for infection control measures during the time of COVID-19 pandemic. This led to numerous private entities engaging in patient gouging, refusal of admission and so on. In India’s mixed health system, out-of-pocket costs and market-based service provision are major payment resources. As a result, to finance and provide services efficiently, the private and public sectors must cohabit in the health sector. Post-COVID-19 health governance necessitates a policy framework in which private entities can operate freely while adhering to carefully crafted government regulations.[10]

To add further, in the upcoming era where preventive and primary health should be the backbone of healthcare, offering equitable, accessible, and quality healthcare to all in developing countries like India is a difficult task to achieve,[11] whereas the same primary health service provision can open windows for private participation under public–private partnership (PPP) modes. During the pandemic, primary health centres were tasked with caring for people with mild symptoms, follow-up care and rehabilitation, contact tracing, triaging and diagnosing COVID-19, promoting public health infection control measures in its catchment area and last but not least vaccination. These all sectors were managed alongside the pre-existing continuum of care. The performance of primary health centres during pandemics points towards strengthening this first line of defence as the foremost policy priority.[12] Favouring private player participation in the primary health sector among many PPP models, a successful model of implementation can be seen in the management of Gumballi Primary Health Centre (PHC) in Southern Karnataka by Karuna Trust (KT). Health indicators drastically improved within one year (1996–97) of passing over responsibility to the trust.[4]

FINANCING

Finally, we want to emphasise the issue of finances. The inclusion of the financing part in line with Wu et al.’s policy capacity framework is highly relevant as financing is one of the critical elements of policy capacity that can affect the implementation of health policies. Financial aspects refer to the ability to mobilise and manage financial resources to support policy development and implementation. Therefore, in the context of the article, financing plays a crucial role in building policy capacity, especially in developing countries, where resources for health services are often limited. With economies stretched and struggling to provide optimal curative treatments, it is difficult for policymakers in developing countries to invest adequately in preventative services. In India, the implementation of a health education cess of 4% of income tax plus surcharges as an earmarked funding source for government welfare services was a noteworthy step.[13] Similar taxation mechanisms can be used, such as fat taxation (e.g. an additional 14.5% tax on purchases of unhealthy food items in Kerala to reduce consumption of unhealthy food), taxing other unhealthy consumptions (tobacco, alcohol), limiting differential taxation on a range of similar products and regular adjustment of these indirect taxes to account for inflation.[14]

To conclude, COVID-19 served as a ‘window of opportunity’ to carefully create a healthy ecosystem with clearly defined tasks and responsibilities at all levels of health governance. Another pressing requirement is to shape PPP laws and regulations to increase private participation while ensuring high-quality, cheap and equitable healthcare.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.