Health Systems and Health Research Systems

Strengthening the links between research and policy making:

Perspectives from India

Seminar: Fudan University, Shanghai, 4th November 2007

Dr. Ravi Narayan, Community Health Advisor,

Society for Community Health Awareness, Research and Action

Bangalore – India.

India- An overview

SOCHARA has worked with the 5 states indicated by red arrows

Some indicators

Population (in 2007):

India 1,135,732,419

China 1,324,441,559

Area (in sq km in 2007):

India: 3,287,590

China: 9,596,960

Per-capita GDP (in USD):

India: 3100

China: 5600

Infant Mortality Rate (per 1000 live births) (UNDP 2005)

India: 63

China: 30

Health Systems in India – An overview

Central

State

District

State

Health

Systems

National Health

Programs

Academic/

Research

NGO/CSO

Private/

Corporate

Non-health

Traditional

POLICY CHALLENGES: CENTRALIZATION VS. DECENTRALIZATION & COMPREHENSIVE VS. SELECTIVE

Health Research Systems in India – An overview

Ministry of Health

Center

State

Academic and research

institutions

CSO

Network of researchers

Research institutions

ICMR, ICSR. Other

Institutions

Private sector

NGO Sector

Planning Commission

State planning board

Task Forces

Consultants

Steering groups

LARGE NUMBERS; MULTIPLE PLAYERS; COMPLEX/ANARCHIC LINKS

Multidisciplinary professional resource network in Public Health/Community Health

Objectives include awareness building, community action, educational strategies, research and policy advocacy

Works with central and state governments; NGOs & CSOs; campaigns and people’s movements and international health agencies

Society for Community Health Awareness, Research and Action

(SOCHARA)

www.sochara.org

Interactive/participatory research with pro-active policy advocacyCase study: Medical Education

Multi-disciplinary task forces collecting qualitative and quantitative evidenceCase study: Karnataka task force for Health

and Family Welfare

People’s tribunals and health watchesCase study: People’s health tribunals (India)

and Global Health Watch (Global)

Strengthening links between research and policy making - Mechanisms

Case study – Medical Education in India

Medico Friends Circle reflections (1991) recommends:

• Community oriented, Socially conscious, primary health care provider

• Multi-disciplinary health analysis and collective societal solution

• Political economy, ethics and value orientation

• Medical teachers – ethics and value orientation and learning facilitation

• Links with peripheral hospitals and community projects

• Institution part of community health/ people’s health network

Case study – Medical Education in India (contd….)

CHC Study on strategies for social relevance and community

orientation (1993)

50 STRATEGIES IDENTIFIED IN

a. Improving pedagogy

b. Additional courses – Behavioral Sciences, Ethics, Rational Therapeutics, Management Health Education, Epidemiology, etc.

c. Skill Development

d. Moving beyond teaching hospitals

e. Transcending Compartmentalization

f. Promoting Self-learning[Source: Annals of Community-Oriented Education –

Network of Community-Oriented Educational Institutions for Health Sciences, Vol 7, 1994]

Case study – Medical Education in India (contd….)

CHC study on medical curriculum reform through graduate

feedback (1993)(50 GRADUATES WORKING IN PHC / PHI)

1. Skill development/independent decision making

2. Involvement in community health programs

3. Examination reform

4. Career guidance

5. Strengthening internship

6. Alternative systems of medicines, ethics, management etc

[Source: Annals of Community-Oriented Education – Network of Community-Oriented Educational Institutions for Health Sciences, Vol 7, 1994]

Case study – Medical Education in India (contd….)

CHC report to Independent commission on Health in India

(1998) recommendations include among others:

• Creative Autonomy for PHC / CH oriented experimentation

• Public Health Capacity/Cadre building

• Research on health policies, health systems and social determinants

• Health team development for PHCs

• People’s Health Movement to counter market orientation and promote HFA as a Right

Case study – Medical Education in India (contd….)

CHC Advocacy with Health University to introduce ethics in undergraduate curriculum (1999)

Ordinance

“The Doctor should be trained to analyze the ethical problems as they arise and deal with them in an acceptable manner. It is therefore recommended that teaching of Medical Ethics be introduced n Phase I and continued throughout the course including the internship period”.

Syllabus

Includes Introduction, perspectives, ethics of individuals, ethics of human life, ethics of family and society, death and dying, professional ethics, research ethics and ethical case work

-RGUHS (1997-98)

Case study – Medical Education in India (contd….)

CHC studies influencing medical education reorientation for

National Rural Health Mission (2000)

EVIDENCE CONSIDERED included

• CHC Studies especially graduate feedback (1993)

• MFC Alternative Curriculum (Medical Education Re-examined) (1991)

And others………….

Refer: http://mohfw.nic.in/NRHM.htm

Case Study - Karnataka Task Force on Health and Family Welfare - 2001

Characteristics: • Twelve members from different sectors

and disciplines (mostly non-governmental)

• Fifty five participatory sessions

• Nine commissioned research studies

• Field-visits

• Invited suggestions through press advertisements

• Two year process with interim report and final report

• Post-task force implementation committee

Case Study - Karnataka Task Force on Health and Family Welfare - 2001

Key Findings:• Corruption

• Neglect of public health

• Distortions in primary health care

• Lack of equity process

• Implementation gap

• Need for ethical imperative

• Human resource development neglected

• Cultural gap and challenge of pluralism

• Ignoring political economy

• Exclusivism rather than partnerships

• Inadequate policy research….

Case Study - Karnataka Task Force on Health and Family Welfare - 2001

Research Study Outcome

Review of externally aided projects in context of integration and sustainability

Integrated HNP policy and project

(Study quoted in CMH/Sach’s Report for

WHO)

Regional disparities in health and health care service

State projects with preferential focus on disadvantaged districts

Does Karnataka need more medical colleges

Task force and health university recommend moratorium on medical college to counter commercialization

Case Study - Karnataka Task Force on Health and Family Welfare – 2001 (contd….)

Karnataka State Integrated Health Policy 2003 (Drafted

by SOCHARA)

Incorporating many key recommendations of the task force and passed through several committee’s and cabinet so that recommendations become part of state policy unaffected by political changes and other influences

Case Study – People’s Tribunals and Health Watches

People’s Health Movement initiated in 2000 (At National

and State levels in India)

“Strong countervailing movement initiated by health and development professionals and activists, consumer and people’s organizations (over 20 networks) to bring health care and medical education and their right orientation high on the political agenda of the country and to ensure that the health policy choices are led by people’s health needs, not market factors”

- Independent Commission on Health in India, 1999

Case Study – People’s Tribunals and Health WatchesCase Study – People’s Tribunals and Health Watches

People’s Tribunals on Denial of right toHealth Care initiated by National Human

Rights Commission & PHM- India (2004 on-wards)Lessons learnt

Peoples evidence strong on corruption, gender discrimination, social exclusion, stigma and system defaults

Structural issues must be documented as key complement to individual experience

True Government – Civil Society Partnership Strong bottom-up pressure for policy change (leading to initiation of

Community Planning and Monitoring of Health Services as an integral part of National Rural Health Mission in 2006)

Peoples voices at national levelPeople’s health tribunals in IndiaCase Study – People’s Tribunals and Health Watches

Global Health Watch – Alternative World Health

Report

Collecting and interpreting evidence for policy change

125 academics/ researchers collate evidence and write contributory chapters for the first alternative world health report released on 29th July at PHA 2

Global Health Watch - IAlternative World Health ReportCase Study – People’s Tribunals and Health Watches

Global Health Watch – Alternative World Health ReportCollaborative project of PHM, GEGA, MEDACT-UK and

many othersStrong on social determinantsAdvocacy document launched worldwideLatin American document also evolved through a local

consultative processOutcomes

Right to Health Campaign starting in many countries Country level reports on health situation Active civil society feed back to WHO commission on

Social Determinants of Health

Global Health WatchAlternative World Health ReportCase Study – People’s Tribunals and Health Watches

www.sochara.org

www.phmovement.org

www.phm-india.org

www.globalhealthwatch.org

http://mohfw.nic.in/NRHM.htm

References