The Flagship Program Approach

The level of coverage of DPT3 (the three required doses of the combined diphtheria, tetanus toxoid and pertussis vaccine) is considered a leading indicator of vaccine coverage in any country. India was in the news recently for having crossed 93% on this indicator in 2022. Senegal has been rated as an exemplar for having moved this indicator from 52% in 2000 to 95% in 2019. These gains have not come easily, and there is much that is valuable to learn from the case studies of these countries.

A common feature of many of the high achievers has been the use of the “flagship program” and other similar vertical approaches. The benefit of such approaches has been to provide a focus on specific, measurable outcomes, with the underlying (often unstated) belief that this will lead to an improvement in the entire health system.

However, as we have seen in several developing countries which have taken this approach, while the flagship program has indeed delivered on its goal, this has not automatically led to the development of a strong health system. I worry that instead of helping, these vertical approaches detract from the goal of building a robust, well-functioning health system.

Good outcomes on vaccinations have not led to the development of robust primary care systems and, going beyond primary care, because of a lack of attention to the entire system, many states and countries have ended up with important fault lines. For example, as I have argued in this piece, in many of India’s focus states and almost all of Africa, the reality that C-section rates are extremely low is now the principal driver of unaddressed maternal and perinatal mortality. The very large Better-Birth trial in Uttar Pradesh in India showed that further improvements from current levels in maternal and child health through primary care interventions alone are not possible.

?I think there is a deeper malaise in national and state-level health systems that needs to be addressed by taking the following steps.

1. We need to consider seriously whether the problem is not a lack of focus within the system (which we hope to address through “flagship programs”) but rather how the system is designed. The older low-trust “count-the-spoons” Semashko model pioneered in Russia under Stalin by Dr. Nikolai Aleksandrovich Semashko, which has now become the preserve of low-performing public sector systems around the world, may well lie at the root of the problem. Within such a system, building more "flagship" programs further fragments the system, takes resources away from non-flagship efforts, and does not address fundamental design flaws.
2. At the other end, there are multiple opportunities to benefit from a “free lunch” on the social determinants end – particularly in areas such as the Built Environment and Economic Stability (Social and Community Context and Education Quality and Access are both also vital but are much harder to alter and also need substantive political will and significant added investment) which can provide quick relief in areas such as infectious diseases and mental illness. However, design guidance to governments on these issues is sorely lacking and needs to be provided. I briefly explore some of these components in my design document for Chhattisgarh (chapter 2).
3. Working with local (state-level in India) and self-funded academic institutions (not grant-dependent think tanks or global NGOs or global universities) to build independent health systems research capacity like Turkey, Thailand, and the Philippines have done. These researchers do not wait for a request from the government but, working over years and decades independently, attempt to build a body of work for the state to learn from. In India, organisations like IHEPA are focused on this capacity-building process. This process is slow and laborious, but I don’t see a way around it. Piecemeal “suitcase” models, which seek to mechanically cut and paste isolated ideas from one health system to another (even our states in India are very different from each other), do not provide a sustainable way forward.

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