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Evidence Matters: Value of Evidence in Health Governance in India

This article was written by Dr Sanjiv Kumar, Director, Indian Institute of Health Management Research (IIHMR) Delhi, and Dr Madhuri Dutta, Head- Grants Management Unit, IIHMR

An efficient health governance system is a prerequisite for a well-functioning health system and achieving national health policy objectives. It is also important to meet sustainable development goal targets and ensuring universal health coverage for all.Evidence helps health governance to create a road map for achieving health targets, it augments knowledge driven policy formulation and encourages community to take ownership of their health through behavior and lifestyle changes. Most importantly, as the below framework indicates[1], evidence encourages innovative partnerships to strengthen national health systems and allows the government and health providers to be accountable for their decisions and their actions.  

 

 

Although efforts in health governance have led to significant progress in India (Under 5 Mortality Rate-126 in 1990 to 48 in 2015, Maternal Mortality Ratio-560 in 1990 to 174 in 2015 and Infant Mortality Rate-80 in 1990 to 38 in 2015), we are yet to achieve many Millennium Development Goal targets at national levels and are farther off on most targets in some states. An evidence based approach can help in a better understanding of challenges in the path and encourage generation of situation specific solutions to these challenges.Evidence can be translated to policy that is relevant to a country’s population and in the same way enrich implementation plans pertinent for people specific needs. The below are some recent examples of evidence to policy and evidence to action from the health governance sector in India.

 

Impact of ‘evidence in policy recommendations’ -

1. National Health Policy 2017- The drafting process involved consultations with all stakeholders from national and state government health sector functionaries, nongovernment agencies, civil society organizations, professional bodies and general public. The first step was a detailed situation analysis documenting evidence from experience in India and outside, as a guide to the policy formulation. 

 

 

Evidence from Situation Analysis[1]

 

Evidence to National Health Policy 2017

       
 
  • Burden of diseases is shifting from Communicable Diseases (28%) to Non Communicable Diseases (60%) and Injuries (12%).
 
  • Revamping of the Primary Health Care infrastructure to ‘Health and Wellness Centers’ to cover entire spectrum of disease profiles while retaining Maternal and Child Health and Family Planning as a priority and induct mid level health care providers.
 
  • Adolescent health profiles define health profiles in communicable, reproductive and nutrition health at later stages of life.
 
  • Integrated efforts at home, Sub centers, and Primary Health Facilities for taking care of non communicable diseases with health facilities to have improved laboratory, physiotherapy and counseling services.
 
  • Health systems related factors contribute only 10% towards health of a population; whereas social determinants of health such as those that define our choices in lifestyle and biological and environmental factors contribute up to 50% and 20% respectively.
 
  • Establishing a continuum of care with digitization of Family Health Records and services such as Auxiliary Nurse Midwifery (ANM) online (ANMOL).
 
  • Disaggregated data for vulnerable groups of population could help in addressing existing inequities in health outcomes.
 
  • Addressing Social Determinants of Health by creating a Health in All Policies, stressing on Water and Sanitation (Swaach Bharat Abhiyan), Nutrition, Addiction and substance abuse, preventing death due to rail and road traffic accidents, taking action against gender violence, improving safety at work places and reducing indoor and outdoor air pollution.
 
  • Although efforts by National Rural Health Mission has led to an increase in selective service delivery in reproductive, child health and a few national disease control programmes, all health needs are not covered.
 
  • Strengthening public trust in public health facilities and enhancing strategic purchasing of selected services from private health sector.
 
  • Urban population has poorer health outcomes and needs a strengthened primary healthcare service provision by the National Urban Health Mission.
   
 
  • 70% of rural population and 80% of urban population utilize private health care facilities.  
   

 

2. Addressing Out Of Pocket Expenditures (OOP) in purchasing health care services-

Evidence- Medicines cost accounts for the largest proportion of OOP health expenses in India. Out of the total expenditure on health, around 72% in rural and 68% in urban areas was made for purchasing medicine for non-hospitalized treatment[2]. 86% of rural population and 82% of urban population were not covered under any scheme of health expenditure support.

Evidence to Policy-The above evidence led to provision for free drugs at public health facilities. This was strengthened by the recent initiative to promote generic drugs at health care facilities. The essential drug list (EDL) is also revised from time to time. The EDL includes commonly used drugs and recently, medical devices have been added to it.

 

 

 3. Standard Treatment Guidelines/Protocols (STPs) –

Evidence- There is wide variation in the way patients with various conditions are treated by different health care providers in both public and private sectors. For some conditions STPs have been developed by professional bodies, international agencies such as WHO, groups set up by the government etc. These groups do not follow a standard methodology and most of the recommendations are based on ‘expert views’ rather than internationally accepted evidence.

Action- A taskforce was constituted by the Ministry of Health and Family Welfare (MoHFW) to develop STPs for common conditions. Firstly a methodology to create STPs was drafted with help from World Health Organization and National Institute of Care and Excellence UK as there was no standard methodology used in India. Ten subject expert groups were involved, that included experts in that specialty, primary health care providers, nursing professionals, patient group representatives and costing experts in the team to develop guidelines based on evidence.  The STPs were then shared with professional bodies and put up in public domain for public inputs. However, two years have passed and approval is still pending from the ministry for implanting the same.

4. Good and replicable innovations and practices-

Evidence- The National Health Mission (NHM) encourages states to carry out innovations to address commonly faced problem in health care delivery. NHM wished to bring states together on one platform for identifying and showcasing their innovative health technology solutions and best practices and provide a cross learning opportunity for cost effective ways for indigenous solutions to indigenous problems.The NHM would also provide financial support to states for implementing/scaling up these innovations and best practices.  However there was no platform available to identify, evaluate and share the practices that were effective, which addressed the burden of diseases and supported the states to scale these up.

Action- With a focus on providing an impetus to this initiative, the government initiated two activities – web –based platform for uploading innovations for review and evaluation and a national summit to share successful innovations and good practices. The first summit was held in 2013 in Srinagar. Letters were sent to states to submit their innovations and MoHFW/NHSRC (National Health Systems Resource Center) teams collected information and documented good practices. Subsequently, the process was streamlined; inclusion/exclusion and evaluation criteria were approved by the Ministry. As a follow up, an online portal, National Healthcare Innovation Portal (NHInP, http://www.nhinp.org/) was launched by the Ministry in the second summit in July 2015 at Shimla. By the third summit held in July 2016 in Tirupati, entries from states had begun to be uploaded on the NHInP site. Some of the factors impeding the program are inadequate review and evaluation system, lack of entries from most states and inadequate attention to scaling up innovations.

Our learning from evidence in health governance

Overall, evidence has helped generate good policy recommendations in India. However it is yet to translate to successful implementation. Implementation plans should focus on factors which enable reaching the last beneficiary. Every implementation programme should also include an accountability framework. This would increase ownership of the programme. A way forward for evidence generation and evidence to action plan would be to encourage implementation research. Academic institutions such as International Institute of Health Management and Research, New Delhi can play an important role in keeping the focus on evidence generation and implementation of the evidence-driven policies. The policies in India are based on strong evidence but implementation leaves a question mark.

References-

  1. ‘Leaders who Govern’- Management Sciences for Health, https://www.msh.org/blog/2015/06/26/how-does-governance-support-health-workers-systems-and-outcomes, June 2015.
  2. Situation Analysis for National Health Policy 2017- National Health Systems Resource Centre, Ministry of Health and Family Welfare, Government of India.
  3. National Sample Survey Office 71st Round (NSSO 71) Report- India Social Consumption Health Survey, Jan-June 2014.

 

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