Primary Health Care
A beginner seeking to understand primary health care could perhaps start with the excellent section on its meaning in the World Health Report of year 2008.
From this collective we begin with a much more contemporary and recent introduction to this theme with the guide-book : Understanding Comprehensive Primary Health Care: The Meghalaya Way. Published in Nov 2022 by National Health Mission, this book was collectively written by a team from CPR, and govt of Meghalaya. This introduction is written for the primary health care providers themselves and for district level teams.
This Ayushman Bharat- Health and Wellness Scheme on which the Meghalaya model is based on the Report of a Task Force to Roll Out Comprehensive Primary Health Care – published by Ministry in the year 2016. This report sets out the conceptual basis of this scheme.
This report itself was part of implementing the mandate to shift from selective primary health care to comprehensive health care as adopted in the National Health Policy 2017. The chronology is confusing, since the operational recommendations pre-ceeded the policy adoption. That happened due to delays in finalization of the National Health Policy due to a discussion on some other aspects. But noting the consensus on this part of the policy- work on the roll-out started earlier.
One of the sources that supported the National Health Policy, or at least some of those worked on the draft was this e-Book: “Archetypes of Inclusive Healthcare: Where Healthcare for the Poor is not Poor Healthcare” . This is a collection of 16 case studies with contributions from over 15 colleagues, It has an introductory and concluding chapter that sets outs the learnings from these case studies for building equitable health systems with emphasis on primary health care. Not all of these are success stories- we also look at examples of what did not work. This collection of case studies was done with assistance from WHO India. WHO office took the lead in presenting these findings as a brief peer reviewed journal paper: “What makes primary healthcare facilities functional, and increases the utilization? Learnings from 12 case studies.” (Lahariya C, Sundararaman T, Ved R, Adithyan GS et al) ,But we would advise the reader to read the full E-book to get the full story.
If your interest is in the politics of primary health care and Health For All then a great publication to start with will be the year 2000 publication by the emerging peoples health movement called “Whatever Happened to Health for All by 2000 AD.” The first draft and subsequent edits of the entire set of 5 publications published for that campaign, were developed through a very participatory process. We note that the lead author for this series and for this web-resource are the same. The rest of the series is also put up and linked to appropriate headings.
Being currently an India-centric collective, we do not have much work to share of global studies- but two interesting articles that we are involved in are: “Tackling the primary care access challenge in South Asia:” Amit Sengupta; Shehla Zaidi, T Sundararaman, Sharad Onta et al” and “Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions“. This paper does not quite do justice to the richness of the discussion at the workshop organized at Bellagio by David Sanders and Chan Swanson, to elucidate the essential features of building equitable health systems- but still it is interesting to document it. The workshop brought together activists, practitioners and academics to discuss approaches to strengthening health systems.
Strengthening Health Systems and Programmes
The organization of health services is one of our main areas of interest. This includes both efforts at strengthening different building blocks of the health system as well as the studying different aspect of health program implementation. In all these studies we take what is called a “ health systems approach.”
A good example of a health systems approach to look at one specific health programme is the case study that was done for the State Human Rights Commission in Maharashtra in 2018. Case Study: The full report is presented here. “An Enquiry into Deaths of Newborns in Nashik , 2018 Presented to Department of Public Health April 6th 2018 On the directions of State Human Rights Commission By team of Prof T Sundararaman and others” . This is a useful case study to teach a systems approach to assessing a public health program/problem.
We will be adding more such problem-solving studies over the coming few months.
In terms of programme evaluation, two important studies are the program evaluation of the Program evaluation of the Janani Suraksha Yojna programme Rajani Ved, Thiagarajan Sundararaman, Garima Gupta1, Geetha Rana et al,. Another is the evaluation of the ASHA programme and important step in our learning and which influenced the subsequent evolution of the ASHA programme in a significant manner. This is presented as part of the section on community health workers.
Another interesting case study, is “Case Study Access to Diagnostics Services in Public Health Sector, Maharashtra” ( T. Sundararaman et al ) that was presented in a workshop. This was an enquiry into how this recent form of public private partnerships was working out. Presented in Workshop on Universal Access to Diagnostics under NHM organized with NHSRC, it was ,used to inform policy, it was never formally published.
One interesting reading from those days is Towards Universal Health Coverage: Reproductive health, and child health and nutrition in India: meeting the challenge. Position Paper on RCH in India.
Another publication of interest- again approaching child health with a systems approach is the paper Role of district health management teams in child health strategies.
Documentation of the health policy and health systems strengthening work done in Chhattisgarh in the period 2002 to 2007 have not survived or become too dated. Our ability to write critically on it was also limited. Much of these areas of work were covered by work done with NHSRC for NHM. This paper dealing with a proximate child malnutrition that we published was Universalisation of ICDS in Chhattisgarh, published in Economic and Political Weekly. Another was the publication in Lancet on Mitanins.
Resilient Health Systems and Pandemic Preparedness
Covid learnings
One aspect of health systems is this and a number of recent publications on the Covid pandemic discuss this.
The most comprehensive publication in this set is our Online Book: Learning from Tamil Nadu s Response to COVID 19 Pandemic: Lessons for the Right to Health Agenda: This was the report of a health activist organized research study by this Arogya Iyyakkam Resource Collective- e-Resources. The report was widely disseminated both in civil society and with key government officers. This had a significant influence on program implementation in Tamil Nadu. It is also a comprehensive review of the entire program.
Another peer review publication emanating from this same study was Discourses around Stigma and Denial in the COVID-19 Pandemic- EPW, Jan 2022, ( S Krithi, Kalpana Karunakaran, J Jeyalydia, R Parthesarathy, T Sundararaman).
Most of the studies done in this period related to the theme of learning from the pandemic for building resilient health systems and pandemic preparedness. Our earlist paper on this theme was “Health systems preparedness for COVID‐19 pandemic” published in the Indian J Public Health as early as June 2020. A shorter version of this was published even earlier : “ Is India’s Public Health System Ready to face the pandemic India in Transition” : by Centre for Advanced Studies in India: U. Penn, as part of its (Ref: Special COVID-19 Series; April 09, 2020.
Another widely cited study which was one of the early studies drawing lessons for building resilient health systems was “Pandemic Resilience and Health Systems Preparedness: Lessons from COVID-19 for the Twenty-First Century.” Sundararaman, T., V. R. Muraleedharan, and Alok Ranjan. Journal of Social and Economic Development , 2021.
Other resources related to the theme of resilient health systems and pandemic preparedness that we share are : Good public health logistics for resilient health systems during the pandemic: Lessons from Tamil Nadu (Adithyan, G. S.2021) in Indian Journal of Medical Ethics, the paper “Emerging Good Practices and Lessons Learnt to Maintain Essential Health Services during the COVID-19 Pandemic” in WHO South-East Asia Journal of Public Health and the book ‘COVID-19: A View from the Margins’ by Dr. Yogesh Jain and Sarah Nabia which explores the deep-seated inequities in India’s health and social systems exposed by the pandemic. Through stories and reflections from 37 contributors, the book examines the pandemic’s disproportionate impact on marginalized communities, emphasizing the need for more resilient and equitable systems in the future.
Two studies related to the theme of health systems resilience relate to the pandemic in rural areas- both published in Review of Agrarian Studies- one in 2021 “Covid-19 in Rural Areas: A Policy Brief,” Sundararaman, T., and Murugan, Ganapathy , and “Challenges to India’s Rural Healthcare System in the Context of Covid-19.” Sundararaman and Alok Ranjan.
One paper “Learning from the Nipah virus outbreak to inform the COVID-19 response in Kerala“ T. Sundararaman, Rakhal Gaitonde and was part of a collection that discussed how learning occurs and was part of a collection discussing how to build systems where learning occurs (Eds: Sheikh K, Abimbola S, editors. Learning health systems: pathways to progress. Flagship report of the Alliance for Health Policy and Systems Research. Geneva: World Health Organization; 2021.)
On vaccination for covid 19 much has been written. We share a detailed article on the policy decisions in this regard published in Frontline as a cover story and an interview in Times of India. The Frontline cover story was titled : “Vaccination against Covid 19- Challenge and an Opportunity,” critically examines readiness and the challenges in India to undertake universal vaccination. The interview is captioned Face-Off in Times of India, May 14, where we argue for vaccination of the entire adult population as an universal and free public programme.
The other theme explored was mortality estimates. This is discussed in an interview, with Sanjiv Sankaran in Times of India May 13, 2022 captioned “Why WHO estimate of death in India is correct “
A more detailed explanatory position paper for public understanding of the Excess Mortality Controversy was shared widely on 13th May 2022 with civil society and officers.
Private Healthcare and Privatization
One important area of health systems studies and practice is in dealing with private health care, privatization , and forms of engagement with the private sector and regulation of the private sector. Regulation is linked to the governance thematic.
Here we begin by the peoples health movement publication of year 2000 called : “Against commercialization of health care.”
Then we present an update on that theme as prepared for the National Health Assembly year in 2018. This publication is titled “Public Private Partnerships”
We then share a paper, published as a chapter in a book, that describes the experience with public private partnerships in India.
We also share the abstract of a paper presented in a conference in 2012: “Business models of public private partnerships in publicly-financed emergency response services” (T Sundararaman Arun Nair Tushar Mokashi Gautam Chakraborthy et al.)
The last selection is a very different piece of work. This is a “Charter for Practicing Responsible Healthcare-Working Document” This was prepared as working document for October Summit 2016 of Responsible Health Care Providers organized by Aravind Eye Hospitals, Madurai. This has participation exclusively from private sector hospitals who were trying to build a constituency of ethical non-commercially driven private health care providers. There are many other such associations and initiatives- small and few but nevertheless very significant.
Health Systems Study Methods and Research
One interesting publication in this regard describes the making of a technical report to guide urban health policy . The Report itself is available in the governance section, but this publication on the making of policy is linked here: Reflections on Participation and Knowledge-Making as Part of India’s National Urban Health Mission, Technical Resource Group Recommendations Exercise (Devaki Nambiar, Rajib Dasgupta, Sundararaman, Pratiba Panwar, et al) .
Yet another case study, available only as an abstract describes the institution of Common Review Mission in the paper: Common Review Mission: reflections on a concurrent evaluation measure. (Pragati Singh T Sundararaman Rajani Ved Padam Khanna et al). The CRM is an annual exercise which began in 2007 and has continued ever since. It has played a significant role in assessing and evolving strategies for strengthening the National Health Mission as a Mission to strengthen public health services as public goods.
We also attach an article on the evolution of effective coverage metrics in health systems , tracing its origins, applications in LMICs, and the need for clearer terminology and systemic improvements to address health system factors affecting intervention effectiveness.