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Health and Population:
Perspectives and Issues
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The National Institute of Health and Family Welfare
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(An autonomous organization under Ministry of Health and Family Welfare, Government of India)
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Baba Gangnath Marg, Munirka, New Delhi – 110067
[k.M 43 la[;k 1 tuojh - ekpZ] 2020 vkbZ,l,l,u 0253 6803
Volume 43 Number 1 January - March , 2020 ISSN 0253-6803
Sustainable Development of Health in India: A Review of the Need for a
Durable Local Collaborative Governance for Strengthening the Health
System
*A. M. Elizabeth, *J. P. Shivdasani, *Vandana Bhattacharya, *Parimal Parya, *Kiran
Rangari, **Subhash Chand, **Bacchu Singh, **Ramesh Gandotra, **Lakhan Lal Meena,
**Y. K. Singhal, **Rita Rani, **Manisha, **Ghanshyam Karol, **Vaishali Jaiswal,
**Rekha Meena, **Sherin Raj T.P., **S. P. Singh, **Sangita Mishra, **Bhawna Kathuria,
**Raj Narayan and ***Harshad Thakur
*** Director, The NIHFW, Munirka, New Delhi- 110067
Reviewers:
Dr. Lam Khan Piang, Department of Statistics, JNU, New Delhi-110067.
Dr. DK Yadav, Department of Statistics and Demography, The NIHFW, Munirka, New Delhi-110067.
Dr. Meerambika Mahapatro, Department of Social Sciences, The NIHFW, Munirka, New Delhi-110067.
Abstract
Health and Population:
Perspectives and Issues, 43 (1): 5-21/2020
Key words:
Introduction
Health is a vital component for the well-being with quality of life and a crucial indicator to
meet the criteria of human development. However, in India, the achievement of optimum
health status is interlinked with other social and distal determinants of life. There has been
visualized by improvement in demographic indicators for health like IMR, MMR, TFR and
increasing life expectancy. But, grading peoples’ health and the health care system across the
states features division between the complexity and inequitable nature of problems, lack of
means and the competence to address it meaningfully across geographical, social, gender,
income and educational strata in different states. The health outcomes always remain low when
the country is compared with other countries with similar economic stages of development.
This is due to the coexistence of high prevalence of preventable diseases, reproductive and
disabilities, unbalanced health care services lacking equity and affordability, lack of public
accountability, poor access to health information, lack of synergy between health research
outcome and its application for development, low government expenditure on public health
though enhanced recently, and large quantum of out of pocket expenses for health by the
individuals which is again pushing the families into more poverty.
The country’s development initiatives commenced upshot in the economic growth for the past
two decades. But this economic development does not seem to shape substantial improvement
in the peoples’ health, rather fail to synergise proportionate investments in health gain bringing
equality and equity among all the segments of the population across states and below level.
At one extreme where best possible health care are provided to those who can afford to pay
for the services including to the people from other countries under medical tourism; on the
other extreme, even the basic or essential service and technologies are unaffordable or lacking
for a large proportion of people who are poor. India ranks 130 among the 189 countries in the
latest Human Development Index (HDI) report. Ranking of India›s quality of life is 49 out of
66 with Quality of Life Index (QLI) of 121.61, health care ratio is 68.04, and the Cost of Living
Index (CLI) is 23.81 (Human Development report 2019).
Further, National Health policy (2017) and NHM (2017) visualize to attain universal access
to equitable, affordable and quality health care services by creating a fully functional,
decentralized and community owned system with greater inter-sectoral coordination so that
wider social determinants affecting health are also equally addressed. Amongst the pool of
strategies designed, it emphasises weightage on decentralized planning with autonomy for
local action, inter-sectoral district health plan including drinking water, sanitation, hygiene,
nutrition; capacity building of Panchayati Raj Institutions, capacity building for preventive
health care at all levels, Health plan for each village through VHNSC, risk pulling and social
and mainstreaming AYUSH and
local health traditions.
Objectives
The objectives of this paper were to:
explore the level of collaboration within and between various players for optimum health;
deeper understanding of current level of inter-sectoral and multi-sectoral collaboration for
health at the local level;
identifying the strength, weakness and disparity which need to be addressed for improving the
sustainable development of health in India; and
suggest evidence-based strategies.
Methodology
The literatures used in this article are from relevant secondary data sources like published
journal articles, government reports, reference papers, etc. published in the decade at the
national and international level. Data particularly focusing on India and developing countries
were selected and down loaded from google.com, pubmed, etc. for review. Further, the content
analysis of various literatures available in the areas was done based on eight broad thematic
Findings
Multi-level Governance, Convergence of Sectoral Programmes and Collaborations for
Health within the Local Health Systems
Over the years, lots of research initiatives have been undertaken to understand the dynamics
of inter-sectoral and multi-sectoral collaboration in the country. PHC governance in Nigeria
illustrates how the multi-level governance framework offers a people-centric lens on the
governance in low- and middle-income countries (LMICs)1. This Nigerian study focuses on
relations among health system actors within and between the levels of governance. The study
demonstrated the potential impact of health system actors functioning at different levels of
governance on PHC delivery, and how governance failure at one level can be assuaged by
governance at another level.
Schneider et al. in their study found collaborations, coordinated action in the community health
system (Zambia), partnership between governmental, non-governmental and academic actors
(India), joint planning and delivery across political and sectoral boundaries (Sweden and South
Africa)2. In this study, four countries’ cases were presented and analyzed using a common
framework of collaborative governance focusing on the dynamics of the collaboration itself.
This collaboration covered principled engagement, collective motivation and joint capacity.
dynamics involved in developing collaborative action in local health systems. These included
the co-construction of solutions (and in some instances, the problem itself) through engagement,
the value of trust, both interpersonal and institutional as a condition for collaborative
arrangements and the role of openly accessible information in building shared understanding.
joint learning and developing shared perspectives are presented as goals in themselves, these
may offset internal and external expectations of collaborations.
Kim et al.3
essential maternal and child health, and nutrition interventions. These interventions are
implemented by two government programmes designed to work together i.e. Integrated Child
Development Services (ICDS) and National Rural Health Mission (NRHM). But it was found
that there is limited understanding of the nature and extent of coordination in place which
was needed at the various administrative levels. Examining how inter-sectoral convergence
between ICDS and NRHM from the state to village levels in Odisha. It was observed that there
was close collaboration at the state level in developing guidelines, planning, and reviewing
programmes facilitated by a shared motivation and recognized leadership for coordination.
However, the health department was perceived to drive the agenda but different priorities and
little data sharing presented challenges. At the district level, there was joint planning and review
meetings, trainings, and data sharing but poor participation in the inter-sectoral meetings and
limited supervision. While the block level is the hub for planning and supervision, cooperation
is limited by the lack of guidelines for coordination, heavy workload, inadequate resources,
and poor communication. Strong collaboration can be materialized by close interpersonal
communication and mutual understanding of roles and responsibilities. The study suggested
that congruent or shared priorities and regularity of actions between sectors across all levels
will improve the quality of coordination, clarity of roles and leadership, and accountability. As
convergence is a means to achieve effective coverage and delivery of services for improved
maternal and child health and nutrition, focus should be on delivering all the essential services
to the mother-child dyads through mechanisms that facilitate a continuum of care approach,
A study by Bossert and Mitchell4 demonstrated that decentralization is a varied experience,
who do so, also tend to have more capacity to make decisions and are held more accountable
should focus on synergies among dimensions of decentralization to encourage more use of de
jure decision space, work towards more uniform institutional capacity, and encourage greater
Health Research, Information and Communication Technologies for Local Health System
Reform
A study on Global research partnerships in advancing public health in India5 reported that
Collaborative research is integral to medicine. Multi-national and multi-institutional research
impact. Developing nations can gain from such collaborative partnerships in achieving progress
in sustainable development goals. However, it is important that the research agenda is relevant
to the region where studies are conducted. Funding of research by the national government and
regional organisations will ensure that the research is appropriate for the region, and ethically
rigorous.
Ward et al.6 examined the extent to which provisions of international health research guidance
promote capacity building and equitable partnerships in global health research. The evaluation
found that governance of collaborative research partnerships, and in particular capacity building,
in resource-constrained settings were limited but had improved with the implementation
guidance of the International Ethical Guidelines for Health-related Research Involving Humans
by the Council for International Organizations of Medical Sciences (CIOMS, 2016). However,
more clarity was needed in national legislation, industry and ethics guidelines, and regulatory
provisions to address the structural inequities and power imbalances inherent in international
health research partnerships. Further, ethical partnership governance was not supported by the
principal industry ethics guidelines. It concluded that governance should stipulate the minimal
requirements for creating an equitable environment of inclusion, mutual learning, transparency
and accountability. Procedurally, this should be supported by (i) shared research agenda setting
with local leadership, (ii) capacity assessments and (iii) construction of a memorandum of
understanding (MoU). Moreover, the requirement of capacity building needs to be coordinated
amongst partners to support good collaborative practice and deliver on the public health goals
of the research enterprise; improving local conditions of health and reducing global health
inequality. It suggested greater commitment, and support should be given to co-ordinate,
strengthen and enforce local laws requiring equitable research partnerships and health system
strengthening.
Borgström7
new ways of thinking, organising and doing to navigate wicked challenges such as climate
change and urbanization. Such challenges call for new governance modes that match the
complexity of the systems where multi-level governance and collaborative approaches have
been suggested to contribute to such transformative capacity building and decentralized
governance of the Stockholm region. Such a collaboration hosts a great potential in supporting
city wide transformation which was hampered by disconnect between actors, levels and sectors,
and the short-term funding structure. The suggested interventions highlight the tension between
ensure sustained space for innovation and learning.
Cash-Gibson et al.8 reported that the effective triangulation of S-N-S partnerships can be of
high value in building sustainable research capacity in LMICs. If designed appropriately, these
multicultural, multi-institutional, and multi-disciplinary collaborations can enable southern
and northern academics to contextualize global research according to their national realities.
Scott et al.9
opportunities for the staff to understand their context and participate in negotiating principles
two organizations, leading to improved implementation of programme and support. The study
suggested that strengthening relationships among those working at the local level by building
collaborative norms and values is an important part of local health system governance for
improved service delivery by multiple actors.
Nyström et al.10 reported that collaborative approaches were important in the study of complex
phenomena. Collaborative approaches were achieved by designing action research or by
involving practitioners from several levels of the healthcare system in various parts of the
research process. Study showed that allocated time, arenas for interactions, skills in project
management and communication are needed during research collaboration to ensure support,
build trust and understanding with involved practitioners at several levels in the healthcare
process. For practitioners, this puts demands on understanding a research process and how it
and evaluating interdisciplinary, collaborative and partnership research.
Study carried out by Scott and Gilson11 reported that Central governance is shaped by the
information and knowledge generated, and used at the lower system levels. Formal health
information is generated in the district-based HIS; therefore, attracts management attention
across the levels of the health system in terms of design, funding and implementation. Hence,
strengthening the local level managers’ ability to create enabling environments is an important
leverage point in local decision-making which in turn, translates national policies and priorities
including equity goals into appropriate service delivery practices. Ramaswamy et al.12 reported
the need for multi-country partnerships to achieve sustainable outcomes in global health but only
a few literature describes how this could be achieved in practice. A strong leadership, support
and engagement of stakeholders, co-creation of solutions with partners, and involvement of
partners in the delivery of solutions are all required for successful and sustained partnerships.
Chandrasekhar and Ghosh13 reported that information and communication technologies (ICTs)
can improve the delivery of health and disaster management services in poor and remote
the availability and delivery of public health services. Educating health professionals in the
possible uses of ICTs, and providing them with access and ‘connectivity’ would give dividends
and also reduce the digital divide.
Surveillance Mechanisms for Health and New Emerging Diseases (Antimicrobial
Resistance)
Dahal et al.14 reported that most of the ‘One Health’ activities in South Asia are determined
by donor preferences. Bangladesh and India did considerable work in advancing
‘One Health’ with limited support from the government agencies. Weak surveillance
mechanisms, uncertain cost-effectiveness of One Health compared with the existing approach,
human resources and laboratory capacity are some of the factors hindering the implementation
of the One Health concept. Implementation of One Health is growing in the South Asian
region with limited or no government acceptance. To institutionalize it, there is a need for
leadership, government support and funding.
A study by Kumar et al.15 reported that Antimicrobial Resistance accounts for the greatest threat
to the health system. The most appropriate path to mitigate this menace was a collaborative,
multidisciplinary approach combining antimicrobial stewardship with infection prevention.
Sustainable efforts to overcome this global problem would require awareness, learning
and coordination at various levels in the health system. Government policies, national
guidelines, collaborative functioning in research, online training modules, and media has an
important role in combating the threat. A multipronged approach involving the infection control
specialist as well as various cadres of health-care providers including pharmacists, nurses
and community-level health workers are needed. All health-care professionals prescribing
antibiotics take responsibility and understand the adverse consequences of inappropriate
and suboptimal antibiotic usage. Certain countries in the world have already in place the
antimicrobial stewardship programme with multi-disciplinary approach. India needs to have
a strengthened anti-microbial stewardship programme involving all cadres of health-care
providers. Brucellosis control will be challenging in India but with collaboration it could be
possible to address these priority areas16.
Strengthening Government Management Capacity
Health Facility Management Strengthening Programme was quite successful in strengthening
the local health governance in the health facilities17. The level of community engagement in
governance improved i.e. an increase in the number of effective HFOMC meetings, expansion
of the inclusion of dalit/women members in the decision-making process, facilitation of
resource mobilization, and community accountability, increase in health facility opening days.
Furthermore, health services became more inclusive as there is an increase in the availability
of technical staff, supervision and monitoring, and display of the citizen charter. Functioning of
HFOMCs is largely dependent on the process of selecting members, the staff and community›s
support, and a sense of volunteerism and team spirit among the members. Correspondingly,
to ensure the effective participation of dalit/woman members, the educational and livelihood
empowerment of the members is very necessary. Furthermore, capacity building and giving
authority to HFOMCs should go hand-in-hand. Local governance of health facilities was
fostered through the local people›s active engagement in HFOMCs and capacity building of
the HFOMC members.
A study on Strengthening Government Management Capacity to Scale up HIV Prevention
Programmes through the Use of Technical Support Units in Karnataka State18 reported
that scaling up HIV prevention programmes among key populations (female sex workers
and men who have sex with men) has been a central strategy of the Government of India.
However, state governments have lacked the technical and managerial capacity to oversee
and scale up interventions or to absorb donor-funded programmes. In response, the
national government contracted Technical Support Units (TSUs), teams with expertise from the
private and non-governmental sectors, to collaborate with and assist state governments. In 2008,
a TSU was established in Karnataka, one of six Indian states with the highest HIV prevalence
in the country where monitoring showed that its prevention programmes were reaching only
assisting in strategic planning, rolling out a comprehensive monitoring and evaluation system,
providing supportive supervision to intervention units, facilitating training, and assisting with
information, education, and communication activities. This collaborative management model
helped to increase capacity of the state, enabling it to take over funding and oversight of HIV
prevention programmes previously funded through donors. With the combined efforts of the
TSU and the state government, the number of intervention units statewide increased from 40
to 126 between 2009 and 2013. Monthly contacts with female sex workers and homosexuals
increased. There were also increases in the proportion of both populations who visited HIV
testing and counseling centers, and sexually transmitted infection clinics and also changes in
sexual behaviours among the key populations were also documented. The Karnataka experience
suggests that TSUs can help governments enhance managerial and technical resources, and
leverage funds more effectively. With careful management of the working and reporting
relationships between the TSU and the state government, this additional capacity can pave the
way for the government to improve and scale up programs and to absorb previously donor-
funded programmes.
Community participation, Social accountability & Decision making within local health
system for Health:
A study has reported that community participation is a complex process which is strongly
carefully considered19. Further, it stated that there is a need for more robustly designed studies
to improve the theorization of community participation, and to draw out a better understanding
its outcomes.
George et al.20 tried to explore the extent, nature and quality of community participation in
health systems intervention research in LMICs. The study highlights that despite positive
examples, community participation in health systems interventions was variable, with few being
truly community-directed. It suggested that future research should more thoroughly engage
with community participation theory, recognize the power relations inherent in community
participation, and be more realistic as to how much community can participate and cognizant
it is vital to provide adequate investment in the ‘people’ component of health systems and
A study21
option through the case of the basic health care provision fund (BHCPF) in Nigeria. The study
Nigeria through the establishment of a fund i.e. Basic Health Care Provision Fund (BHCPF).
The strategies for accountability encompass planning mechanisms, strong and transparent
monitoring and supervision systems, and systematic reporting at different levels of the health
care system. Further, it highlighted that non-state actors, particularly communities, must be
empowered and engaged as instruments for ensuring external accountability at lower levels
of implementation. New accountability strategies such as result-based or performance-based
transparency and corruption in the health system, political interference at higher levels of
government, poor data management, lack of political commitment from the State in relation to
release of funds for health activities, poor motivation, mentorship, monitoring and supervision,
suggested accountability mechanisms due to political interference.
A Tanzanan study22 reported that almost all the stakeholders viewed Accountability for
Reasonableness as an important and feasible approach for improving priority-setting and health
service delivery in their context. However, a few aspects of Accountability for Reasonableness
Tanzania. The highlights of the study are budget ceilings and guidelines, low level of public
awareness, unreliable and untimely funding, as well as the limited capacity of the district to
generate local resources as the major contextual factors which hampered the full implementation
of the framework. The study suggested that Accountability for Reasonableness framework
could be an important tool for improving priority-setting processes in the contexts of poor-
resource settings. However, the full implementation of Accountability for Reasonableness
would require a proper capacity-building plan, involving all relevant stakeholders, particularly
members of the community as public accountability is the ultimate aim, and it is the community
that will live with the consequences of priority-setting decisions.
A study in Gujarat23 on how social accountability contributes to better maternal health outcomes
with government and civil society actors, showed an improved interaction between communities
and the health system led to better access to and use of maternal health services. However, the
lack of capacity and ownership of the government structures.
A study by Panda and Thakur24 reported that the robustness of a health system in achieving
the desirable outcomes depends upon the width and depth of ‘decision space’ at
the local level. However, lack of consensus on an acceptable framework followed by notion
the ‘continuum of health services’ model, the challenge often lies in identifying variables
service delivery outputs, etc.). Compartmentalizing the local decision making and its effect
on health system performance revealed that there is scanty evidence about innovations
to quantify characteristics of governance at institutional, system and individual levels except
through proxy means. There is a need to sensitize the governments and academia about how
best more objective evaluation of ‘shared governance’ can be undertaken focusing on context-
Administrative Decentralization, Local Self-Governance and Leadership for Health
Rogi Kalyan Samiti (RKS)
George et al.25 reports that more focus is placed on strong local leadership but no attention is
to develop skills were crucial for community participation, critical thinking, problem solving
and ownership. There are many quantitative scales for measuring community capability but
health systems research engaged with community participation rarely made use of these tools
or the concepts informing community. Thus, strengthening community capability becomes
critical for ensuring community participation which leads to genuine empowerment.
A study of the functioning of the local self governance in health repots that poor knowledge/
expectation of RKS members was weakening the decision making process at peripheral decision
making health units (DMHUs)26. Thus, a locally-monitored and time-bound capacity building
plan to improve their knowledge, understanding and expertise in the areas of governance and
the differences underlying individual and systemic factors between Priority District (PD) and
Non-Priority District (NPD) needs to be initiated.
According to Kwamie et al.27, administrative decentralization followed by incomplete political
with strong vertical accountabilities and dependence of the district on national level. Thus,
it demonstrates that the expression of decentralization does not always mirror the actual
implementation, and neither it empowers the lower level authorities. A study conducted in
the Philippines in 201928, reported that at institutional levels, these desired capacities should
include having a multi-stakeholder approach, generating revenues from local sources,
partnering with the private sector and facilitating cooperation between local health facilities.
On the other hand, adjustments in accountability should focus on the various mechanisms that
can be enforced by the central level not only to build the desired capacities and augment the
inadequacies at local levels but also to incentivize success; and regulate failure by the local
governments in performing the functions transferred to them. The study concluded that to
optimize decentralization in the health sector, widening decision spaces for local decision-
makers must be accompanied by the corresponding adjustments in capacities, and accountability
for promoting good decision-making at lower levels. Further, analyzing the health system for
its synergy is useful for exploring concrete policy adjustments in the Philippines as well as in
other settings.
A study conducted in 201629 reported that Rogi Kalyan Samiti (RKS) was established at every
services. However, understanding on quality improvement strategies was found to be very
poor among the health workers. Customized capacity building measures at the district and sub-
district levels could be critical to equip the peripheral health units to achieve the universal health
coverage goals. Work environment, systemic factors and accountability must be addressed on
status of population needs intense analysis.
Adsul and Kar30 have reported that RKS has yet to bring out quality component to the health
services being provided through facilities by bridging the structural and managerial weakness
in the system. The progress of the RKS needs to be enhanced by giving due priority to the
critical areas. Furthermore, the results should emphasize an urgent need for devising strategies
Rawat et al.31 reported that the main functions performed by the RKS included infrastructural
strengthening of the CHCs, improvement in basic facilities, ensuring provision of emergency
medical care, free medicines, basic laboratory and radiological investigation, transport
the community members were not aware of the existence, objectives and the activities of RKS.
The innovations applied by the best performing districts need to be incorporated in the national
guidelines. Additionally, targeted capacity building activities for the district health managers
may improve their decision-making abilities which will contribute to improve health system
performance.
Resource Management (Manpower and Finance)
Singh et al.32 have reported that the decision on expenditure of untied funds of CHCs and
PHCs was taken in the meeting of Rogi Kalyan Samiti (RKS) but the members from other
sectors such as PRI, education, revenue department, etc. usually did not attend the meeting.
fund. About 50 per cent of the ANMs stated that they were unable to expend the money due
to non co-operation of the Pradhan. In majority of the cases, the decision on the utilization of
untied fund was taken by the ANM herself instead of VHSC meeting. The study suggested
utilization, strict monitoring of utilization of the untied fund at each and every level are needed.
Sheikh et al.33 have reported that proper deployment or posting and transfer (P&T)
of health workers- placing the right people in the right positions at the right time is vital
the health system as a principal social institution. P&T is an unsettled issue in many low and
middle-income countries which requires strong political commitment for improving the public
sector services coupled with new thinking and research for inter-disciplinary collaboration and
implementation. This can further strengthen other areas in HRH and health systems. Further,
innovative social science and management theorizing, iterative, and locally-driven interventions
that focus on establishing transparent professional norms and building the credibility of
government administration, including the health services, are likely the way forward.
Seshadri et al.34 reported that Karnataka had devolution of all 29 functions prescribed by the 73rd
Amendment by the late 1990s. An evaluation of the impact of decentralization in the health sector
found virtually no change in the health system performance. No improvement was also found on
access to health services in terms of availability of health personnel or in various health indicators
such as IMR or MMR. However, there has been a conscious effort under the National
Rural Health Mission (NRHM) to promote decentralization of funds, functions to the lower
levels of government. Overall, the data indicate substantial gap between the NRHM guidelines
on decentralization and the actual implementation. Thus, there is a need for capacity building
at all levels of the health system to fully empower the functionaries, particularly at the district
Using community-based evidence for Health reform:
A study has been conducted on using community-based evidence for decentralized health
planning in Maharasthra35. A project on capacity building for decentralized health planning
was implemented in selected districts of Maharashtra, India during 2010-‘13. This process
a process for community feedback and participation towards health system change. The
evaluation of the project included in-depth interviews of various participants and analysis of
change in local health planning processes. The study revealed positive changes in intervention
areas, increase in capacity of key stakeholders leading to preparation of evidence-based
health facility funds, and inclusion of community-based proposals in village, health facility-
based block and district plans. Further, transparency related to planning increased along with
responsiveness of health providers to community suggestions. The key lesson was that active
participation is essential to ensure changes in planning. Further, capacity building of diverse
stakeholders in the local health planning and advocacy to enable participation of community in
the planning process is essential. This combination of strategies emphasizes on the framework
of ‘empowered participatory governance’ which combines a degree of ‘countervailing power’
and acceptance of participation by the system for new forms of governance to emerge.
Discussion
The health policy and programmes highlight the need of governance in health for distribution
of responsibility and accountability between the centre and the state. These policies
recommend equity, sensitive resource allocation, strengthening the institutional mechanism
for consultative decision- making as well as coordinated implementation as mechanisms
to achieve it. It visualizes strengthening Panchayati Raj Institutions to enhance their role at
different levels of health governance including social determinant of health making community-
based monitoring and planning mandatory. Thus, it places people at the centre of the health
system and development process for effective monitoring of quality of services and for better
accountability in management and delivery of healthcare services. It focuses to increase both
horizontal and vertical accountability of the health system by providing a greater role and
participation of local bodies, encouraging community monitoring and programme evaluation
along with ensuring grievance redressal systems effective. The policy recognizes the essential
of Sustainable Development Goals by highlighting the quantitative indicators with target-
from departments like Women and Child Development, Education, WASH, Agricultural and
Food and Civil Supplies with MoHFW in the role of convener to monitor and ensure effective
optimal outcomes.
The current review projected various challenges and dynamics involved in developing
through engagement, building trust both interpersonal and institutional for collaborative
arrangements and making information accessible in building shared understanding. Eventually,
of sectoral programmes for health, the health department was perceived to drive the agenda but
different priorities and lack of data sharing poses challenges. Additionally, the members from
other sectors such as PRI, education, revenue department etc. usually did not actively participate
in the meeting highlighting the lack of wiliness to coordinate at the local level. Further, the sub-
district level and below level are the junctions for planning and supervision but face challenges
due to lack of clear guidelines for coordination, cooperation, heavy workload, lack of resources
and communication. It requires more synergies among the various dimensions to work towards
more uniform institutional capacity, encouraging greater accountability to local governance.
There is a need to congregate health research with local issues for suggesting evidence-based
solution. Moreover, the capacity building needs to be coordinated amongst partners to support
good collaborative research practice and deliver on the public health goals of the research
activity initiated for improving local conditions for optimum health and reducing the health
inequality.
Innovation of new dimensions of service provisions like people-centric integrated models of
services, community-based delivery, community accountability, quality improvement, and
e- health technologies have been conceptualized as a practical solution to hit the millstone.
However, these reforms to revamp the health system are often characterized with inarticulate
state in organizational fragmentations and functioning. It resulted in variety of forces impacting
the health system and proliferation of donor aid and vertical health programme particularly
during the period of Millennium Development Goals. The latest Public Health management
to compete rather than collaborate. Hitherto, addressing these complex health needs requires
new and better coordination between levels and players within the health system as well as
between the health and other sectors especially at local level.
To ensure active community participation, educational and livelihood empowerment of the
community is very necessary. Local governance of health facilities needs to be promoted
through the local people’s active engagement in the health programme. It requires capacity
building of the local health professionals and community members for strengthening the local
government management capacity for health. Ensuring quality of community participation in
health is vital to provide adequate investment in the ‘people’, accountability of health systems
is a substantial gap between the NRHM/NHM guidelines on decentralization and the actual
implementation. Thus, there is a need for capacity building at all levels of the health system
to fully empower the functionaries, particularly at the district and below levels. These reforms
for health system strengthening.
Conclusion
There has been an overall improvement in the provision of health care infrastructure, human
resource development but more pro-action was needed considering the country’s failure to
achieve many of the targets. The status of health of the people still stays way below the world
average. This raises questions about the strategic implementation mechanism at different
stages of the programmes on removing the regional and gender disparities. The diversifying
nature of the problem, quantum and differential stages of development between regions call
Without active involvement of the communities, achievement of primary health target is going
health system strengthening by capacity building of the local self-governance institutions like
Panchayati Raj Institutions to enhance their role at different levels of health governance. This
will address issues such as the social determinants of health, community-based planning and
monitoring in order to place people at the centre of the health system and development process.
For effective monitoring of quality of services and better accountability in management of
healthcare services, active involvement of local bodies is a must. Further, the study concludes
that harmonious or shared priorities and regularity of actions between sectors across all levels
will likely to improve the quality of coordination. Focus on leadership and accountability is
imperative to achieve these goals. Without active involvement of communities achievement of
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LokLF; ,oa tula[;k:
ifjizs{; ,oa eqn~ns, 43 (1): 5-21/2020
