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Figure 1: Ontological framework of Health System
Webinar Report:
Ramaiah Webinar on Health Systems During Covid-19
in Collaboration with Narayana Hrudayalaya Limited
Covid-19 has been pushing the health systems across the globe to their limits. Apart from
the primary functions and providers of healthcare delivery, secondary level activities and
actors for service delivery, resource mobilization, capacity planning, surveillance informatics
are proving to be critical in optimizing the health system. New and innovative measures
have been undertaken within the scope of the system. The episode of the pandemic, thus,
has a massive potential to provide important feedback for learning in health systems re-
search.
The Ramaiah Webinar on Health Systems during Covid-19 in collaboration with Narayana
Hrudayalaya Ltd. was organized on 20th August 2020, as a step towards systematically deriv-
ing learnings for health system management from the response to the pandemic. The panel
discussion was based on an ontological concept map of health systems illustrated in figure
1. The panellists comprised ex-bureaucrats, academicians, researchers, and practitioners
from diverse backgrounds related to public health, journalists, and health sector administra-
tors. The discussion followed a form of free-flowing interaction among the panellists facili-
tated by the moderator.
Monad Map of Webinar Discussion
Assisted by the framework, the discussions were analysed systematically post-event. A
monad map illustrating the spread and scattering of discussion points is constructed based
on the coding of the panel exchanges as displayed in the figure 2. The number in parenthe-
ses adjacent to each element of the map reveals the frequency of its occurrence in the pan-
el discussion. The data bar beneath each element visually indicates the frequency of occur-
rence, but it is proportional to the number to help visualize relative emphasis.
Systemic Function* Scope Core Function** Provider** Recipient Outcome*
Governance International Care Primary Healthcare Patient Equity
Service Delivery National Curative Hospital Family Efficiency
Human Resources State Rehabilitative Residential Caretaker Effectiveness
Information District Long-term Ambulatory Community Transparency
Financing Village Preventive Ancillary Others Accountability
Research&Development
Ward Strategic Management Preventive Care Responsibility
Mobilization Medical Good Innovation
Infrastructure Administrative
Supply Chain Insurance
Equipment Secondary Service
Medicine Household
Personnel Public
Administration Private
Ancillary Service NGO
Laboratory
Transportation
Imaging
[in healthcare]
System Core Processes
[by/through]
[providers to/for]
[level for]
[at]
[for]
2
The panel exchanged thoughts responding to the following initial question raised by the fa-
cilitator: What are some of the learnings as gaps in multiple aspects of the health system
such as governance, human resource management, information, financing and R&D in re-
sponse to Covid-19? The monads map shows that the panel covered all the dimensions and
elements in the framework though with varying emphasizes. The important issues raised are
summarised in the following sections organized according to the systemic functions in the
ontology which received the highest attention according to the analysis. It will also address
their interaction with other dimensions in the ontology whenever relevant.
Governance & Leadership
Issues regarding governance received the highest priority in the panel discussion. Debating
on the appropriate governance structure, it weighed the pros and cons of centralization and
decentralization in decision making during the pandemic. While the centralized and stand-
ardized strategies were argued to be necessary during a disaster, the need for understand-
ing and addressing of the local level dynamics and community participation were weighed
against it. Ultimately, it calls for identifying the most efficient and effective level (Scope) to
undertake the functions of the health system. It was submitted that nurturing leadership at
the local level is required in the long-term for sustainable solutions. The need for institu-
tions of eminence that can guide the response to the pandemic was also raised. Apart from
the governance structure, the public trust and competency of the leadership were high-
lighted. Community commitment and cooperation are significantly effective during pandem-
ic and trust in the incumbent is the key.
The lack of coordination among the stakeholders especially between the public and private
providers continued to be an issue even during the pandemic management. It is high time
for collaboration between public and private providers in the areas of surveillance and
treatment in line with the experiences from HIV and RMNCH programs in the past. There is
Figure 2: Monad Maps of Webinar Discussion
Systemic Function* (32) Scope (15) Core Function** (7) Provider** (15) Recipient (6) Outcome* (13)
Governance (20) International (1) Curative (2) Hospital (6) Patie nt (4) Equity (2)
Service Deli very (5) National (7) Rehabilitative (0) Re sidential (0) Family (0) Efficiency (3)
Human Resources (12) State (6) Long-term (0) Ambulatory (0) Caretaker (0) Effe ctiveness (4)
Information (10) District (6) Preventive (1) Ancil lary (0) Communi ty (3) Transparency (2)
Financing (6) Vill age (0) Mobiliz-Infrastructure (3) Preventi ve Care (0) Others (0) Accountabil ity (1)
Research&Developme nt (11) Ward (5) Mobiliz- Supply chain (1) Medical Good (0) Responsibili ty (1)
Mobiliz-Equipment (1) Administrativ e (1) Innovation (6)
Mobiliz-Medicine (0) Insurance (0)
Mobiliz-Pe rsonnel (4) Household (0)
Administration (0) Publi c (6)
Ancill- Laboratory (1) Private (6)
Ancill- Transportation (0) NGO (4)
Ancill- Imaging (0)
[for]
System Core Processes
[at]
[level for]
[by/through]
[providers to/for]
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a major need for formally engaging the informal sector-providers who are largely involved in
providing routine services to a large section of the population especially in the rural and pe-
ri-urban areas.
Service Delivery
It has been observed that service delivery must be coordinated for optimization. It has re-
sulted in a lack of utilization of the existing surveillance and strategic capacities available in
the system. It has become difficult to organize during the pandemic when it was not
achieved before the pandemic. The assessment of existing resources which can be utilized
and delivered efficiently needs to be done. This must be done in its interaction with the var-
ious components in the core functions and with a focus on efficiency in outcomes in the sys-
tem.
Human Resources
Human resource capacities in the public and private sector must be tapped and coordinat-
ed. It has been identified that there are huge number of specialist vacancies at the commu-
nity health centres and district hospitals. The lack of financial resources is also an impedi-
ment in recruiting and training of the required capacity of human resources.
It is also noted that there are cases of systemic negligence to the role of certain human re-
source pool. Nurses even though constitute the frontline staff and are critical in Covid-19
treatment, for instance are yet to be integrated into the leadership positions in the system
formally. It is evident in the fact that there are no leadership positions for them at govern-
ment central, state, or district levels of the public healthcare system. The issues in human
resources must be understood and addressed in its interaction with the provider dimension
in the ontology. Assessing the requirements and capacities for different providers and func-
tions and planning for capacity filling is the way forward.
Information
The role of the media in awareness generation and image development has become im-
portant. Ensuring appropriate information is disseminated to the public is crucial in multiple
aspects. It ensures public trust in the system providing avenues for community participation
and cooperation on the one hand and on the other, helps enable proper accountability and
transparency mechanisms in the system. Popular media has an important role to play in this
respect. It was argued that the image created in the media regarding the private hospitals in
the country has been negative. It was suggested that public perception of the private hospi-
tal sector must be changed to such that it will enable better integration of the latter to the
health system.
Financing
The chronic deficiency in funding for the health sector has proved to be critically disrupting
healthcare delivery during the pandemic. While policy documents including the 2001 health
policy proposed increase in health expenditure to 2-3 percent of the total GDP, they are yet
be realised on the ground. The deficiency of funding in the sector coupled with Covid-19 and
the resulting surge in the expenditure has resulted in the expenditure cuts on other public
health programs related to Tuberculosis and RCH. This can have a long-term impact on the
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health system. Understanding of the health system investment and expenditures, reforms in
devolution mechanisms between the governments are the way forward.
Research & Development
There is a consensus on the fact that the pandemic has reinforced the need for solution-
oriented research in the health system. Moreover, the availability of evidence has become
necessary for instant decision making. The panel discussed what are the impediments in
generating quality evidence despite a lot of data being generated during the pandemic. For
instance, there have been success stories in the form of Dharavi and some of the better per-
formed states. However, generating evidence during the pandemic continues to be difficult
due to operational issues. It was also suggested that there should be more interaction be-
tween the researchers and the front-line workers in the lines of collaboration during the HIV
and RMNCH programs in the country. Academia needs to be more solution oriented and
relevant to the dynamic context. Research needs to get revamped attention at the policy
level and innovation should be an explicit outcome of the system.
Others
Anecdotes of Success, Alternative Medicine etc.
The instance of Dharavi has been raised in the context of multiple dimensions of the health
system functioning. It is a case of community and civil society partnerships, of success in a
broken health system and of local level decision making in pandemic management. They
deserve to be systematically documented and replicated in other parts of the country.
There is also the need for understanding that a lot of public health solutions are situated
outside the health sector. Factors like water and sanitation, housing and environment re-
quire significant attention at this juncture. Measures of physical distancing and sanitation
protocols rely on these factors and thus become an impediment for large sections of the
population.
Alternative and traditional methods of medicine and tools were also discussed. It was ar-
gued that AYUSH care, where a lot of potentials and advantages exist for the country, could
not be utilized in the regime of evidence-based medicine.
Conclusions and Way Forward
The panel discussion observed that the pandemic for the most part has only exacerbated
the existing failures in the health system rather than posing new types of troubles. The is-
sues to be addressed are chronic and systemic and thus require long-term solutions. The
pandemic has also revealed important learnings for the health system reform in the form of
stories of successes and failures which needs to be systematically researched and docu-
mented. Situating the learning in the socio-economic, political-cultural, and institutional
context is also crucial.
Based on the analysis of the discussion using the ontological framework, the webinar pro-
vides the following themes as a road map for research and practise going forward:
• Assessment of the financial allocations and expenditure and its interaction with in-
ter-governmental relationships
• Establishing Institutional frameworks identifying optimal administrative levels and
defining roles for undertaking health system functions.
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• Identifying coordination points for the public-private collaboration and utilization of
resources to optimize service delivery
• Encouraging academic endeavours at the policy level to learn from the stories of
successes and failures and contribute to evidence-base
List of Panellists
Sl.No
Name
Designation and Affiliation
1
Dr.Ananth Bhan
Adjunct Faculty, Kasturbha Medical College, Mani-
pal/University of Torrento
2
Dr.Anupama Shetty
Head-CSR, Narayana Hrudayalaya
3
Dr.Chidambaram Murthy
Principal Scientist, Ramaiah Medical College
4
Dr.Krishna D. Rao
Assistant Professor, Department of International
Health, John Hopkins University
5
Dr.Krishnamurthy Jayanna
Associate Dean: Research & Professor, Ramaiah University
of Applied Sciences, India.
6
Dr.Maulik Chokshi
Director, Health System, Access Health International
7
Dr.Nagendra Swamy
Principal Coordinator, Federation of Healthcare Associa-
tions, Karnataka
8
Dr.Nanda Kumar BS
Associate Professor, Ramaiah Medical College
9
Dr.Naresh Shetty
President, Ramaiah Memorial Hospital
10
Dr.Prasanth Desai
Director, School of Law, Ramaiah University of Applied Sci-
ences
11
Dr.Priya Seetharaman
Professor, Management Information Systems, IIM Calcutta
12
Dr.Rajeev Sadanandan
CEO, Health System Transformation Platform, TATA Trust
13
Dr.Shankar Bhakkanavar
Associate Professor, MAHE, Manipal
14
Dr.Shibu Vijayan.
Global TB Technical Director, PATH
15
Dr.Sonali Jadhav
Principal, Ramaiah Institute of Nursing Education and Re-
search
16
Dr.Soumyadeep Bhaumik
Research Fellow, The George Institute for Global Health
17
Mr.Ravi Duggal
Independent Researcher and Activist
18
Mr.Srivara
Chief HR and legal, Gokula Education Foundation
19
Mr.Tushar Mokashi
Senior technical Specialist, Access Health International
20
Ms.Patralekha Chatterjee
Independent Journalist
21
Ms.Sujatha Rao
Former Health Secretary, Government of India
22
Prof.Dr. G. G. Gangadharan
Director, Ramaiah Indic Speciality Ayurveda Hospital
