Highlights from November 2023
Health Systems Transformation Platform
HSTP is a not for profit organisation. Enabling Indian Health Systems Respond to People's Needs.
Welcome to The Transformation Tracker, the second issue of the Health Systems Transformation Platform’s (HSTP) monthly newsletter that brings you the latest news, insights, and achievements from HSTP. This edition focuses on our work in strengthening public health systems across diverse domains and geographical locations, striving to enhance healthcare quality, accessibility, system resilience, and accountability.
The edition covers:
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As a strategic partner to the Government of Meghalaya for strengthening its health system, HSTP conducts research and shares evidence-based recommendations to bridge gaps and enhance public health services. This month, a draft policy for Specialist and Public Health Cadres developed based on a comprehensive assessment by HSTP has been opened for public input. Additionally, the state-wide rollout of Internal Performance Agreements where HSTP provides technical assistance to the Department of Health, has marked a significant stride toward a more robust healthcare system.
HSTP’s support areas in the state of Meghalaya include health financing, resource planning for health, Human Resources for Health (HRH), and digital health. The team undertakes research to facilitate evidence-based decision-making in policy and program implementation. The goal is to address current gaps within the health system, enhance the delivery of public health services, and ultimately improve health outcomes within the state.
HRH Policy – Specialist and Public Health Cadre
The healthcare workforce, or Human Resources for Health (HRH) is a critical component of healthcare delivery. Policies governing HRH directly impact the availability, distribution, competency, and satisfaction of the healthcare workforce, which, in turn, influences healthcare quality, accessibility, and availability across the country. Despite their importance, however, the evaluation of HRH policies in states remains an underexplored area in India. Recognizing the pivotal role of HRH policies in achieving universal health coverage and addressing emerging health challenges, HSTP is dedicated to assessing and addressing critical gaps in HRH policies across states.
On invitation from the state government, HSTP conducted a comprehensive health system assessment in Meghalaya, revealing a shortage of Specialists with Medical Officers functioning from a common pool in the public health system. This imbalance in the availability of HRH posed a unique challenge for the state, not just from the perspective of the citizens but also the Specialists and Medical Officers for their career opportunities, aspirations, progression, and retention. Thus, it necessitated a thorough examination of HRH policies to ensure an optimal healthcare workforce.
To tackle these challenges, team HSTP conducted an in-depth analysis of the state-specific HRH policies against the need to provide specialised and general health services. This analysis identified gaps that limited the absorption and progression of Specialists and Doctors within the state public health system. In response to these findings, HSTP formulated a set of recommendations, emphasizing the creation of specialist and public health cadres as a crucial step toward enhancing the availability of specialised health services in the state. Aiming to capture contextual issues and gaps in the implementation of HRH policies, the team actively participated in multiple rounds of expert committee consultations, collaborating with representatives from the Directorate of Health Services, District Level Officers, Meghalaya Health Systems Strengthening Project (MHSSP), and practising Specialists and Doctors within the health system.
As a key milestone in this process of working with the state’s HRH policies, HSTP provided technical support to the State Health Department in developing a state-specific Policy for the Creation of Specialist, Public Health, and Teaching Sub-Cadres governing their caderisation, service rules, recruitment, posting, transfer, and career progression. We are pleased to announce that on November 9, 2023, the draft policy document was made available on the State Health Department's website for comments from experts and the public at large. This marks a significant step towards a more robust and responsive healthcare system in Meghalaya.
Implementation of the Internal Performance Agreement
HSTP also provides technical assistance to the Department of Health, Meghalaya, in implementing the Internal Performance Agreements (IPAs) in the state. IPAs can be used as a mechanism to appropriately plan, allocate, and spend resources based on needs to improve service delivery in the state.
In the process of supporting the state in identifying priority areas, HSTP conducted a situational assessment. Health interventions that require strengthening in Meghalaya were identified through stakeholder consultations facilitated by the team, which included meetings with the Directorate of Health Services, District Health Officials, members from the Program Management Unit of the Meghalaya Health Systems Strengthening Project (MHSSP), practising Specialists, and different categories of healthcare providers.
The readiness of existing health facilities to implement the IPAs identified was also assessed by HSTP. This led to frameworks and activities being developed for the different IPAs implementing units along with indicators to measure performance. A pilot test of the IPA frameworks across selected health facilities was conducted by the team to check the feasibility of the proposed activities and outcome indicators. The indicators were revisited and finalised based on the pilot.
The intent of this exercise has been to develop IPAs that align with the nuances of the state’s requirements, with the flexibility to adapt to consequent findings and challenges revealed in the process of implementation. This prioritisation of health care needs, strengthening of the quality of care, and optimisation in resource utilization aims to bolster the delivery of health care services in the state.
HSTP takes great pleasure to announce that the state-wide roll-out of IPAs in Meghalaya was launched on 1st November 2023.
A unique endeavour in India, the Bhopal Healthy City project is an initiative by HSTP in collaboration with the Government of Madhya Pradesh and Swasti. The project showcases a concerted effort towards comprehensive urban healthcare planning in alignment with the WHO Healthy City framework. Starting in 2021 in Indore, the project moved its focus from Indore to Bhopal, following the objectives of the state government, and gained substantial momentum with approval from the Additional Chief Secretary-Health, Government of Madhya Pradesh.
This project focuses on understanding the impact of different determinants of health on urban health. The significance of this concept arises from the necessity of a multifaceted approach to urban healthcare, given the numerous healthcare concerns faced by rising urban populations. Acknowledging the interconnection of different aspects that impact general well-being, the five main pillars of this project are health, water, food and nutrition, environment, and sanitation.
The team has conducted extensive research from available data and consultations with various departments and experts across the five thematic areas. The project, though impacted by the outbreak of the pandemic, has now completed the processes of establishing the governance and management mechanisms, creating high-level task forces across relevant departments, drafting a comprehensive framework aligned with the WHO Healthy City model, establishing a baseline, and developing the key indicators that will shape the outcomes of the project.
The purpose of this initiative is to develop a plan for a model "Healthy City" by tackling present issues in health, water, nutrition, the environment, and sanitation.
A model healthy city will:
India is undergoing a significant shift in healthcare demands, particularly in the realm of home healthcare. The shift can be majorly attributed to demographic changes, including an ageing population and a rise in chronic illnesses. For these areas of concern, home healthcare aims to improve patient outcomes, enhance quality of life, reduce hospital readmissions, and provide holistic care in a comfortable and familiar environment. However, despite this steadily increasing demand, the field of home healthcare in the country remains significantly under-researched.
Pallavi Gupta, Sonali Randhawa, and Sunil Nandraj from the Health Systems Governance team at HSTP explored this field in their recent article “The Home Healthcare Boom: Opportunities and Obstacles in India’s Changing Healthcare Landscape”. The article discusses the several critical concerns and challenges that persist in the provision of home healthcare services ranging from accessibility, availability, regulatory issues, standards of care, costs, safety, and grievance redressal mechanisms for both service providers and users. The lack of information about the services, providers, and organizations offering home healthcare services further compounds these challenges.
From their analysis, the team has recommended the need to redefine the concept of "home" as a viable site for healthcare delivery and as a legitimate "workplace" for care providers. The article also advocates for standardised protocols and guidelines for delivering various forms of care at home, emphasizing the diversity of conditions that might require home-based care. It also prioritises the necessity for uniform human resource practices in deploying care providers, transparent cost calculations and regulations, and the establishment of effective grievance redressal mechanisms for users, providers, and organisations.
The article calls for further research in the domain, including a deep dive into the perspectives of both users and providers, refining the training and supervision protocols for care providers, and scrutinizing the financing, accreditation, and overall quality of home healthcare services.
Team HSTP is committed to working on the recommendations outlined in the article. To avail copies of the article and our research, please write to us at [email protected].
In a consultation organized by the Health Resilience Platform Team of the Asian Venture Philanthropy Network (AVPN) in Singapore, Pranay Lal (Senior Advisor, HSTP) was invited to share his expertise on the ‘One Health’ paradigm.
The consultation aimed to engage the AVPN member community in a thoughtful exploration of the approach and its relevance for the dynamic landscape of Asia. It sought to draw perspectives from diverse participants representing corporate foundations, financial institutions, philanthropic foundations, impact funds, and more. The thematic focus of the discussion revolved around key aspects of the One Health approach, delving into its interpretation, relevance in the contemporary world, potential for promoting equity and inclusion, institutionalization in the Asian context, the role of innovative finance, and effective collaboration among key stakeholders.
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Here is an overview of Pranay’s contributions to the consultation, shedding light on his perspectives and recommendations regarding the multifaceted dimensions of the One Health approach.
In the ever-evolving landscape of global health challenges, the 'One Health' approach has emerged as a critical strategy, recognizing the intricate interdependence of human, animal, and environmental health. Pranay, through his presentation on “Perspectives on One Health Approach and its Relevance for Asia” focused on advancing public health equity through the lens of One Health. He delved into the multifaceted dimensions of this integrated approach and its specific relevance to the Asian context.
Understanding One Health: Pranay began by emphasizing the comprehensive nature of the One Health approach, highlighting its role in preventing, predicting, detecting, and responding to global health threats. With a significant portion of infectious diseases being zoonotic in origin, One Health becomes paramount in addressing the complexities of emerging diseases. Lal underscored that the interconnectedness of human, animal, and environmental health is not just a matter of safeguarding individual health but is intrinsically tied to broader aspects of economic, political, and environmental stability.
He shed light on the intricate web of infectious disease transmission, emphasizing the need for a holistic strategy that considers the origins, spillover events, and potential pathways of transmission. He also highlighted the intensifying effects of climate change on health risks, requiring a comprehensive approach that addresses both direct and indirect impacts.
Role of Innovative Finance in One Health: Pranay articulated the indispensable role of innovative finance mechanisms in effectively implementing the One Health approach. He stressed that beyond conventional models, interventions must span diverse areas such as climate mitigation, prevention of deforestation, animal trade regulation, data surveillance, active case finding, and drug and vaccine discovery. Lal emphasized the importance of directing investments toward prevention, policy development, and infrastructure in vulnerable areas post-disasters.
Specific Actions for Asia: While speaking about the Asian context, he also provided a roadmap for the global community in Asia to advance the One Health approach which covered:
Equity and Inclusion in One Health: Highlighting one of the significant advantages of the One Health approach, Pranay underscored its potential to bring about equity and inclusion. He emphasized the importance of empowering diverse stakeholders, including farmers, wildlife conservationists, and marginalized communities, in disease prevention efforts. He stressed the need for equitable access to resources and information, especially in vulnerable regions, as a fundamental factor for the success of the One Health approach.
Pranay’s presentation provided a comprehensive and insightful exploration of the transformative potential of the One Health approach in advancing public health equity in Asia. By focusing on building resilient health systems that transcend traditional boundaries, he emphasized the need to embrace the interconnected nature of global health challenges.
Issues such as impact of climate change on health, One Health and Anti-Microbial Resistance are often assigned to sector specialists to manage, without recognising their significance for the entire health system. For instance, climate change impacts most diseases, either directly or indirectly. Understanding the pathways of impact will assist prevention and mitigation. If policy makers recognise the causality between a climate event and an increase in disease burden it would stimulate investments on research in this area.
To illustrate, epidemiologists map the seasonality of diseases. Traditionally some diseases occur in certain periods, partly due to the increase in vectors during favourable climatic conditions. But if the weather cycles or monsoons become erratic, the predictability of infectious diseases is lost. Epidemiologists will then need to disaggregate each causative factors and then assess their impact. For instance, an unseasonal rain may leave puddles in peri domestic spaces where Aedes mosquitoes could grow leading to a dengue epidemic at a time when it is not anticipated. Rain should then become a red flag for public health officials to act. We have seen spikes in vector-borne diseases in abnormally hot years. However, the connection between weather conditions and infectious disease is not fully known and needs to be researched to plan an intervention. Similarly understanding the relationship between heat and pollution will improve our ability to mitigate their impact on pulmonary diseases.
At HSTP we are engaged in sensitising policymakers to understand the importance of issues such as climate change, One Health and AMR in health management. We hope to persuade governments to set up structures and systems, with budget provisions and competent staff, to manage them. Given the lack of familiarity with the issues these are likely to be standalone interventions to begin with. But we hope to mainstream them with the health system in the future.
HSTP Highlights
HSTP Shortlisted for Multisite Implementation Research on Strengthening HWCs in India by ICMR
Health and Wellness Centres (HWCs) in India are integral to the nation's healthcare infrastructure, aiming to deliver Comprehensive Primary Healthcare Services (CPHC) with a focus on preventive care and health promotion. These centres serve as the initial point of contact for communities, providing a range of essential health services that alleviate the burden on higher-level healthcare facilities, facilitate early detection of health issues, and foster community well-being. As part of the broader strategy for achieving Universal Health Coverage, HWCs play a vital role in enhancing healthcare access, improving service quality, and bolstering India's public healthcare system.
In keeping with the need to improve primary healthcare, the Indian Council of Medical Research (ICMR) issued an invitation for Expressions of Interest to conduct a multisite implementation research, on optimising equitable quality CPHC services through Ayushman Bharat Health and Wellness Centres.
This effort, spearheaded by ICMR, aims to address the challenges associated with the delivery of CPHC across the nation by:
We are glad to share that the joint proposal submitted by the Regional Medical Research Centre (RMRC), Bhubaneswar, and HSTP was shortlisted. Post shortlisting, along with team RMRC, Pratheeba, Sudha, and Ankur from team HSTP participated in a protocol development workshop conducted by ICMR. Over three days, our team collaborated with counterparts from diverse organisations spanning eight different sites to develop the common protocol in the presence of distinguished experts including Dr Rajiv Bahl (Director General of ICMR), and Dr Vinod K. Paul (Member of NITI Aayog).
Gap Assessment of District Hospitals in Chhattisgarh
Strengthening district hospitals in India serves multiple purposes, primarily focusing on enhancing healthcare accessibility, providing quality medical services closer to communities, reducing the burden on higher-tier healthcare facilities, improving healthcare outcomes, addressing public health challenges, and ensuring a more comprehensive healthcare delivery system at the grassroots level. Towards this objective, a comprehensive assessment of the District Hospitals in the state is a priority for the partnership between HSTP and the Government of Chhattisgarh in enhancing its healthcare landscape. HSTP is working closely with the Department of Health and Family Welfare. The aim is to align them to the Indian Public Health Standards (IPHS) 2022 norms by facilitating evidence-based decision-making processes to inform and guide context-specific policy and program implementation. This adherence aims to ensure standardized service quality, efficient resource allocation, and transparency in healthcare delivery.
This gap assessment covers various critical elements, including the assessment of infrastructure, equipment, human resources, and the availability of essential drugs and diagnostics across a range of services and departments in district hospitals. This district hospital assessment is comprehensive in identifying critical gaps in service provisions and serving as the foundation for state planning based on the needs uncovered, thereby enabling the formulation of budgetary requirements to ensure the effective allocation of necessary resources.
To maintain transparency and coordination, data collection for the assessment is supported by hospital managers of the district hospitals. Recently, at a state-level capacity building programme, all hospital managers have received training to know and understand the IPHS norms and the inputs in the IPHS gap assessment checklist.
Stay tuned to our progress on these vital projects through our website, social media, and further editions of The Transformation Tracker!
About HSTP
Health Systems Transformation Platform (HSTP), a not-for-profit Indian organisation, aims to generate evidence on health policy and systems and promote the use of that evidence in policymaking. HSTP's strategy is to analyse the state of the healthcare system, identify opportunities for improvement, propose solutions to the state government, support them in the implementation of the accepted ones, and validate them through implementation research. We then turn our analysis, implementation research and findings into knowledge products, that are available for use in alternative situations so that our research can achieve a scale large enough to make a difference at the national level.
HSTP is a not-for-profit organization registered in the name of 'Forum for Health Systems Design and Transformation', a company licensed under section 8 of the Indian Companies Act 2013.