In our recent chapter in the ORF–OCPP Global Policy volume “Securing the 21st Century Mapping India-Africa Engagement”, we argue that future health systems in India and Africa are going to become more alike than they have been before, and that it is crucial for them to learn from each other. We analyze two types of health system innovations – one from each setting – which represent key opportunities for such cross-learning. When first approached by the editors of the volume, we were hesitant, aware of the problem of comparing a country with a continent. But we also appreciated that the potential for mutual learning is great, and that is the spirit in which we wrote the chapter. Our chapter reflected an Indian perspective on India-Africa engagement on health. The other chapter in the section on health in the volume is written by a Ghanaian author Franklin Cudjoe.
India and many African countries have long shared similar challenges – widespread poverty, social inequities, demographic transition, ecological degradation, and a prevailing infectious disease burden co-existing with emerging epidemics of non-communicable diseases and injuries. Overlaid on these challenges and fueled by fast-paced urbanization and the spread of private commerce, is the common experience of mixed health systems. Mixed health systems as used here means more than the mere coexistence of public and private health care. Rather, we use it in the sense of Nishtar 2010 referring to the phenomenon of unregulated private sector growth contextualized by inattention to and stagnant expenditure for health in the public sector.
We start our chapter by describing the emergence of mixed health systems across Africa, as we have already seen in India. Mixed health systems seem to offer more choices for people, but also hold considerable risks of compromised quality and equity. We then describe two types of health system innovations (one from each setting) with the potential to counteract these risks – (i) local participatory governance reforms in India, and (ii) the empowerment of non-physician health care providers in several African settings.
In India, local participatory governance reforms substantially started with the 73rd Constitutional Amendment Act in 1992. A three-tier system of Panchayati Raj Institutions (PRIs) was established at the village, sub-district, and district levels, in a process of wide-scale administrative devolution. PRIs have responsibilities for multiple sectors including sanitation, primary education, infrastructure development, and health. Their health sector responsibilities include establishing health centers at village and sub-district level and supervising and monitoring health services. The outcomes of such decentralization are mixed in different states; however, the state of Kerala showcases a scaled-up model of strong local governance incorporating community engagement as an integral part of health sector planning and delivery. The state allocated 35-40% of the funds to programmes developed by PRIs. This has improved people’s participation in planning, health service responsiveness, access to primary healthcare, and political and administrative accountability. Kerala’s story tells us that constitutional and legal provisions are an important pre-requisite for giving people a say in how health systems are organized – possibly an experience from which African countries and other Indian states can learn.
On the other hand, India can clearly learn from multiple African experiences of empowering non-physician health workers. Transferring more responsibilities to nurses and mid-level workers has helped expand access to healthcare and address chronic shortages of physicians, in many African countries. Expanded training has equipped them to carry out a significant number of diagnostic and therapeutic tasks otherwise restricted to physicians. They manage regular clinic visits, Caesarian sections, hernias, closed fracture care, and amputations in several settings. South Africa is a case in point, where the health system is nurse-based and nurse-driven. Malawi’s experience suggests that paramedical clinical officers can safely perform surgery when adequate training and supervision are provided. The presence of mid-level health practitioners in the Mozambican health system has been reported to lead to a significant reduction in referrals and cost of care. Over the years, several policy initiatives in India have attempted similarly to empower nurses and non-physician providers – but with less success and sustainability. Hopefully, India’s new Ayushman Bharat scheme with its emphasis on mid-level health care providers will mark a new chapter in this respect.
Within as well as beyond the confines of the health sector – democratizing innovations are the key to strengthening health systems. For Indian health sector reformers, there are clearly lessons to be learnt from African experiences of democratizing the internal governance of health services and the health professions by empowering non-physicians. Whereas in Kerala, legal reforms institutionalizing health systems’ accountability to communities provided a pathway to better health equity and quality. It is sobering that these innovations – important as they are – are restricted to specific states or countries, and they certainly need wider traction. Indian and African health systems have more in common than is widely recognized. Their respective departments of health, research universities and think tanks, and civil society groups must collaborate more and learn from each other (and from other countries with relevant experiences) on the path to democratizing their respective health systems.
Read the book here. Chapter 7 is ours.
Views expressed are the authors’ own and not those of their organizations.