Decentralization of Health Services: The Kerala People's Campaign

National Rural Health Mission reforms in light of decentralised planning in Kerala, India: a realist analysis of data from three witness seminars

BACKGROUND

The People's Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history.

METHODS

We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning.

RESULTS

Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM's frontline health workers, ASHAs, emerged as leaders in LSGs.

CONCLUSION

The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation - these contradictions may vex progress going forward and warrant further study.

Monitoring the Family Health Centres in Kerala, India: Findings from a facility survey

Introduction

Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the "Aardram" health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs.

Materials and Methods

We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders.

Results

Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders.

Conclusion

Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time.

A critique of the policy discourse on primary health care under the Aardram mission of Kerala

In 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.

Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19

BACKGROUND

In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state's health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19.

METHODS

A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30-63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts - transliterated into English-were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

RESULTS

LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services.

CONCLUSION

Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Horizontal inequity in the utilisation of Continuum of Maternal Health care Services (CMHS) in India: an investigation of ten years of National Rural Health Mission (NRHM)

BACKGROUND

Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16.

METHODS

We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups.  Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity.

RESULTS

The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable.

CONCLUSIONS

Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and  granting greater power to the states might lead to equitable distribution of CMHS.

The legacy of public action and gender-sensitivity of the pandemic response in Kerala State, India

Kerala State, India has received global attention in its response to the Covid-19 pandemic. Its response effectively attended to the health pandemic and focussed on economic relief. This paper attempts to understand how gender-responsive Kerala's policies were. Kerala's success was due to its historical preparedness and contemporary policy innovations. Over the years, public action was able to ensure that the state and the society were equipped to meet the challenges of a disaster, such as of the pandemic. In the 1990s, when India sought to limit state intervention and promote market-based solutions, public policy in Kerala shifted gears to deepen state intervention by promoting community participation and empowering women. As in other Indian States, the pandemic in Kerala too led to losses of female employment, rise in gender-based violence, a deterioration of women's mental health and rise in unequal care burdens. But Kerala's response was distinctive. Several policy interventions had foregrounded women's needs, which helped ensure gender-sensitivity in Kerala's pandemic response. Kerala's economic relief package included cash support, employment, free food provision and zero-interest loans to women. Through helplines, the government reached out and helped women report instances of violence and mental stress. The gender-sensitivity of Kerala's pandemic response is a rich guide as a demonstration of its possibilities and a reminder of the essential pre-requisites to achieve it.

Relying on serendipity is not enough

The novel coronavirus has caused a global public health crisis, and impacted countries irrespective of their development status. The health system preparedness has varied across countries, necessitating a hard look at how resilient health systems can be built to withstand the onslaught of sudden pandemics and epidemics. India has been grappling with the onslaught of COVID-19 since the last 6 months of the current year, bringing into focus the ability of its health system to withstand the pressures of dealing with such a pandemic. In this context, the paper analyses India's health sector by focusing on infrastructure, personnel, financing and governance, to enable a better understanding of the extent of resilience in India's health system. Using data from the latest household survey on health, the paper also looks at the disease profile of care seekers to illustrate why COVID transmission is likely to be rapid in the country, the potential impact of COVID care on non-COVID care, the groups that are most likely to forego care due to the lockdown and the diversion of resources to COVID care, choice of providers and out-of-pocket expenditure evidenced from such choice. The paper concludes that a country cannot effectively deal with a pandemic and reduce its socioeconomic impact by trying to fix its health system in real time. The lesson from the COVID era would be for India to immediately start with the much delayed health sector reforms, beginning with a substantial jump in public health financing, if impact of future epidemics and pandemics are to be minimised.

COVID-19: Need for Equitable and Inclusive Pandemic Response Framework

When a new infectious disease emerges as an epidemic or pandemic, strict and appropriate mitigation strategies are critical. Appropriate steps that facilitate defining of cases, carrying out accurate clinical diagnoses, and forming a powerful health surveillance that addresses public health policies and procedures are necessary. Tracking the number of COVID-19 cases over time and flattening the curve is another important element to establish research settings and identify therapeutic components to expedite and develop effective interventions. Addressing the various sections of the society in a philanthropic way is crucial to acquiring the public cooperation that is essential to controlling a disease like COVID-19. In this study, we discuss various strategies and measures adopted by Kerala, an Indian state, to combat the COVID-19 outbreak. Regular and timely updates by government public relations and health departments were used in many of the adopted strategies. The engagement of health information systems, together with the application of decentralized governance and community engagement, has contributed to effective population health management and surveillance of the pandemic.

Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries

Health committees, councils or boards (HCs) mediate between communities and health services in many health systems. Despite their widespread prevalence, HC functions vary due to their diversity and complexity, not least because of their context specific nature. We undertook a narrative review to better understand the contextual features relevant to HCs, drawing from Scopus and the internet. We found 390 English language articles from journals and grey literature since 1996 on health committees, councils and boards. After screening with inclusion and exclusion criteria, we focused on 44 articles. Through an iterative process of exploring previous attempts at understanding context in health policy and systems research (HPSR) and the HC literature, we developed a conceptual framework that delineates these contextual factors into four overlapping spheres (community, health facilities, health administration, society) with cross-cutting issues (awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social movements and inequalities). While many attempts at describing context in HPSR result in empty arenas, generic lists or amorphous detail, we suggest anchoring an understanding of context to a conceptual framework specific to the phenomena of interest. By doing so, our review distinguishes between contextual elements that are relatively well understood and those that are not. In addition, our review found that contextual elements are dynamic and porous in nature, influencing HCs but also being influenced by them due to the permeability of HCs. While reforms focus on tangible HC inputs and outputs (training, guidelines, number of meetings held), our review of contextual factors highlights the dynamic relationships and broader structural elements that facilitate and/or hinder the role of health committees in health systems. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and clarifies areas for investigation and action.

Health system regionalization in Canada's provincial and territorial health systems: do citizen governance boards represent, engage, and empower?

Regionalization of the health care system, through the creation of sub-provincial service-delivery regions and governance authorities (i.e., regional health authorities, RHAs), has been a key part of Canadian health reform initiatives of the past two decades. Increased public participation in health care planning and service delivery is one of the explicit goals of regionalization. Based on a reanalysis of data from a 2001 survey of health system governors from 134 RHAs throughout Canada, this study explores the overall demographic composition of the citizen governance boards, as well as their responses to various opinion and attitude questions. To enable consideration of the extent to which these sites may support public deliberation and community development, overall responses are examined, as are responses within two subtypes of governors: system-experienced citizen governors and lay citizen governors--governors with or without previous health-system employment experience, respectively. The findings suggest that attention needs to be paid to these citizen governance boards if they are truly meant to be sites of citizen engagement in health policy and governance.