The Barriers to Universal Health Coverage in India and the Strategies to Address Them: A Key Informant Study.

Background: India has adopted several policies toward improving access to healthcare and has been an enthusiastic signatory to several global health policies to achieve Universal Health Coverage (UHC). However, despite these policy commitments, there has been limited success in realizing these goals. The COVID-19 pandemic has highlighted the urgent need for health system re-design and amplified the calls for such reforms. Objectives: We seek to understand the views of a diverse group of policy actors in India to address the following research questions: what are the (i) conceptualizations of UHC, (ii) main barriers to realizing UHC, and (iii) policy strategies to address these barriers. Data and Methods: We collected data through in-depth interviews with 38 policy actors from diverse backgrounds and analyzed using the Framework Method to develop themes both inductively and deductively using the Control Knob Framework of health systems. Findings: There was congruence in the conceptualization of UHC by policy actors. Quality of care, equity, financial risk protection, and a comprehensive set of services were the most commonly cited features. The lack of a comprehensive systems approach to health policies, inadequate and inefficient health financing mechanisms, and fragmentation between public and private sectors were identified as the main barriers to UHC. Contrasting views about specific strategies, health financing, provider payments, organization of the delivery system, and regulation emerged as the key policy interventions to address these barriers. Discussion and Conclusion: This is the first systematic examination of a diverse set of policy actors' problem analyses and suggestions to advance UHC goals in India. The study underscores the need to recognize the complex and interlinked nature of health system reforms and initiate a departure from path-dependent vertical interventions to bring about transformative change.

Private pharmacies as healthcare providers in Odisha, India: analysis and implications for universal health coverage.

INTRODUCTION: In India, as in many low-income and middle-income countries, the private sector provides a large share of health care. Pharmacies represent a major share of private care, yet there are few studies on their role as healthcare providers. Our study examines: (1) What are the characteristics of and services provided by private pharmacies and how do these compare with other outpatient care providers? (2) What are the characteristics of patients who opted to use private pharmacies? (3) What are the reasons why people seek healthcare from private pharmacies? (4) What are the quality of services and cost of care for these patients? Based on our findings, we discuss some policy implications for universal health coverage in the Indian context. METHODS: We analyse data from four surveys in Odisha, one of India's poorest states: a household survey on health-seeking behaviours and reasons for healthcare choices (N=7567), a survey of private pharmacies (N=1021), a survey of public sector primary care facilities (N=358), and a survey of private-sector solo-providers (N=684). RESULTS: 17% of the households seek outpatient care from private pharmacies (similar to rates for public primary-care facilities). 25% of the pharmacies were not registered appropriately under Indian regulations, 90% reported providing medical advice, and 26% reported substituting prescribed drugs. Private pharmacies had longer staffed hours and better stocks of essential drugs than public primary-care facilities. Patients reported choosing private pharmacies because of convenience and better drug stocks; reported higher satisfaction and lower out-of-pocket expenditure with private pharmacies than with other providers. CONCLUSION: This is the first large-scale study of private pharmacies in India, with a comparison to other healthcare providers and users' perceptions and experiences of their services. To move towards universal health coverage, India, a country with a pluralistic health system, needs a comprehensive health systems approach that incorporates both the public and private sectors, including private pharmacies.

The Politics of Health Policy Agenda Setting in India: The Case of the PMJAY Program.

In 2018, India's Prime Minister announced a new health insurance program, Pradhan Mantri Jan Arogya Yojana (PMJAY), aiming to cover over 500 million people. This paper seeks to document and explain the emergence of PMJAY on India's political and policy agendas. We analyze media, election manifestos, legislative debates, and health budgets to compare PMJAY's presence on India's policy agenda to previous health programs. We then apply Kingdon's Multiple Streams Framework to explain the program's emergence and adoption, validating our data and interpretations through consultations with Indian health policy experts. Comparing respective launch years, PMJAY was covered in national newspapers 37 to 212 times more than previous flagship health programs, although it was not more prominent in parliamentary debates or in the health budget. Events in the problem, politics, and policy streams converged to enable its prominence. Health policy elites who favored insurance as a policy to address out-of-pocket health expenditures gained influence after the 2014 election victory of the Bharatiya Janata Party (BJP). PMJAY's naming and branding, scale, timing, implementation style, and design aligned with both the BJP's ideology and political strategy. PMJAY represents the increased prominence of health programs in Indian politics, although primarily on the political and media agenda, rather than on the budgetary and legislative agenda during this period. The political forces that facilitated its emergence also shaped its design in ways that are likely to affect the Indian health system's ability to provide comprehensive financial protection in the future.

Comprehensive Assessment of Health System Performance in Odisha, India.

India has recently implemented several major health care reforms at national and state levels, yet the nation continues to face significant challenges in achieving better health system performance. These challenges are particularly daunting in India's poorer states, like Odisha. The first step toward overcoming these challenges is to understand their root causes. Toward this end, the Harvard T.H. Chan School of Public Health conducted a comprehensive study in Odisha based on ten new field surveys of the system's performance to provide a multi-perspective analysis. This article reports on the assessment of the performance of Odisha's health system and the preliminary diagnosis of underlying causes of the strengths and challenges. This comprehensive health system assessment is aimed toward the overarching goals of informing and supporting efforts to improve the performance of health systems in Odisha and other similar contexts.

Catastrophic health expenditure on private sector pharmaceuticals: a cross-sectional analysis from the state of Odisha, India.

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha-a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities-yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7-40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1-0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha-supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Public health research in India in the new millennium: a bibliometric analysis.

BACKGROUND: Public health research has gained increasing importance in India's national health policy as the country seeks to address the high burden of disease and its inequitable distribution, and embarks on an ambitious agenda towards universalising health care. OBJECTIVE: This study aimed at describing the public health research output in India, its focus and distribution, and the actors involved in the research system. It makes recommendations for systematically promoting and strengthening public health research in the country. DESIGN: The study was a bibliometric analysis of PubMed and IndMed databases for years 2000-2010. The bibliometric data were analysed in terms of biomedical focus based on the Global Burden of Disease, location of research, research institutions, and funding agencies. RESULTS: A total of 7,893 eligible articles were identified over the 11-year search period. The annual research output increased by 42% between 2000 and 2010. In total, 60.8% of the articles were related to communicable diseases, newborn, maternal, and nutritional causes, comparing favourably with the burden of these causes (39.1%). While the burdens from non-communicable diseases and injuries were 50.2 and 10.7%, respectively, only 31.9 and 7.5% of articles reported research for these conditions. The north-eastern states and the Empowered-Action-Group states of India were the most under-represented for location of research. In total, 67.2% of papers involved international collaborations and 49.2% of these collaborations were with institutions in the UK or USA; 35.4% of the publications involved international funding and 71.2% of funders were located in the UK or USA. CONCLUSIONS: While public health research output in India has increased significantly, there are marked inequities in relation to the burden of disease and the geographic distribution of research. Systematic priority setting, adequate funding, and institutional capacity building are needed to address these inequities.

Impact of community-based mitanin programme on undernutrition in rural Chhattisgarh State, India.

BACKGROUND: Community health workers known as mitanins undertook family-level counseling and mobilized the community to improve coverage of maternal and child health services in the state of Chhattisgarh, India. The Nutrition Security Innovation (NSI) project was launched in selected blocks with additional inputs for promoting appropriate complementary feeding practices and disseminating information on Public Distribution System (PDS) entitlement. Within 3 years of project implementation, all NSI inputs in the project group (PG) were scaled up in the entire state. OBJECTIVE: To study the impact of interventions on nutritional status in PG and non-NSI comparison group (CG) blocks. METHODS: Quasi-experimental mixed methods were used. The sample consisted of 3,626 households with children under 3 years of age and 268 mitanins. RESULTS: A ratio of 1 mitanin per 250 to 500 population was effective. The coverage of exclusive breastfeeding, timely introduction of complementary feeding, DPT immunization, and antenatal care services was more than 70%. The PDS reached almost 90% of beneficiaries. In both the PG and the CG, one-third of children were undernourished, with one-quarter of children undernourished by 6 months of age. The prevalence of low birthweight was over 40%, and half of all women were undernourished. The estimated annual average reduction rate (AARR) for the entire state was estimated to be 4.22% for underweight and 5.64% for stunting. CONCLUSIONS: The strategy of Mitanin Programme in the Indian state of Chhattisgarh was unique with the implementation of direct nutrition actions being spearheaded by the health sector and community health volunteers in coordination with the Integrated Child Development Services (ICDS) and the Public Distribution System (PDS). The highest priority was given to interventions in the first 92 weeks of life. This implied ensuring frequent counseling and delivery of services through the entire pregnancy period and continued follow up till the children were at least one year of age. An accelerated decrease in the annual rate of reduction of underweight and stunting was observed. The emerging findings point to the significant contributions that can be made by the National Rural Health Mission (NRHM) in India by involvement of community health volunteers known as Accredited Social Health Activists (ASHAs) towards reducing the persistent problem of undernutrition in the country.

Role of innovative institutional structures in integrated governance. A case study of integrating health and nutrition programs in Chhattisgarh, India.

PURPOSE: The aim of this paper is to highlight the significance of integrated governance in bringing about community participation, improved service delivery, accountability of public systems and human resource rationalisation. It discusses the strategies of innovative institutional structures in translating such integration in the areas of public health and nutrition for poor communities. DESIGN/METHODOLOGY/APPROACH: The paper draws on experience of initiating integrated governance through innovations in health and nutrition programming in the resource-poor state of Chhattisgarh, India, at different levels of governance structures--hamlets, villages, clusters, blocks, districts and at the state. The study uses mixed methods--i.e. document analysis, interviews, discussions and quantitative data from facilities surveys--to present a case study analyzing the process and outcome of integration. FINDINGS: The data indicate that integrated governance initiatives improved convergence between health and nutrition departments of the state at all levels. Also, innovative structures are important to implement the idea of integration, especially in contexts that do not have historical experience of such partnerships. Integration also contributed towards improved participation of communities in self-governance, community monitoring of government programs, and therefore, better services. PRACTICAL IMPLICATIONS: As governments across the world, especially in developing countries, struggle towards achieving better governance, integration can serve as a desirable process to address this. Integration can affect the decentralisation of power, inclusion, efficiency, accountability and improved service quality in government programs. The institutional structures detailed in this paper can provide models for replication in other similar contexts for translating and sustaining the idea of integrated governance. ORIGINALITY/VALUE: This paper is one of the few to investigate innovative public institutions of a and community mobilisation to explore this important, and under-researched, topic.

Empowering health personnel for decentralized health planning in India: The Public Health Resource Network.

The Public Health Resource Network is an innovative distance-learning course in training, motivating, empowering and building a network of health personnel from government and civil society groups. Its aim is to build human resource capacity for strengthening decentralized health planning, especially at the district level, to improve accountability of health systems, elicit community participation for health, ensure equitable and accessible health facilities and to bring about convergence in programmes and services. The question confronting health systems in India is how best to reform, revitalize and resource primary health systems to deliver different levels of service aligned to local realities, ensuring universal coverage, equitable access, efficiency and effectiveness, through an empowered cadre of health personnel. To achieve these outcomes it is essential that health planning be decentralized. Districts vary widely according to the specific needs of their population, and even more so in terms of existing interventions and available resources. Strategies, therefore, have to be district-specific, not only because health needs vary, but also because people's perceptions and capacities to intervene and implement programmes vary. In centrally designed plans there is little scope for such adaptation and contextualization, and hence decentralized planning becomes crucial. To undertake these initiatives, there is a strong need for trained, motivated, empowered and networked health personnel. It is precisely at this level that a lack of technical knowledge and skills and the absence of a supportive network or adequate educational opportunities impede personnel from making improvements. The absence of in-service training and of training curricula that reflect field realities also adds to this, discouraging health workers from pursuing effective strategies. The Public Health Resource Network is thus an attempt to reach out to motivated though often isolated health workers. It interacts with, and works to empower, health personnel within the government health system as well as civil society, to meaningfully participate in and strengthen decentralized planning processes and outcomes. Structured as an innovative distance-learning course spread over 12 to 18 months of coursework and contact programmes, the Public Health Resource Network comprises 14 core modules and five optional courses. The technical content and contact programmes have been specifically developed to build perspectives and technical knowledge of participants and provide them with a variety of options that can be immediately put into practice within their work environments and everyday roles. The thematic areas of the course modules range from technical knowledge related to maternal and child health and communicable and noncommunicable diseases; programmatic and systemic knowledge related to health planning, convergence, health management and public-private partnerships; to perspective-building knowledge related to mainstreaming gender issues and community participation. Currently the Public Health Resource Network has been launched in four states of India--Chhattisgarh, Jharkhand, Bihar and Orissa--in its first phase, and reaches out to more than 500 participants with diverse backgrounds. The initiative has received valuable support from central and state government departments of health, state training institutes, the National Rural Health Mission--the current comprehensive health policy in the country--and leading civil society organizations.