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 73^rd 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.

Using the data from HSR 2016, this blog will zoom in on the regional imbalances in knowledge production. From the abstracts selected for oral presentation at the symposium (total 259), I compared the region of the research institutions and the region of the data collection. I framed a few questions to understand the asymmetries in knowledge production as evidenced by the symposium. The main observations are given below.

What does a comparison between the regions of data collection and institutions of the first author tell us?

There is an uneven representation of regions of research and institutions performing the research. Discounting the theoretical presentations from the total number of abstracts, the analysis shows that the majority (87%) of the studies used data from Asia, Africa or Latin America. However, 45% of the institutions of first authors were located in Europe, the United States, Canada or Australia (see figure 1). Zooming in on individual countries, the highest share of first author institutions was found in the United States (17%), followed by the United Kingdom (12%), Canada (9%), and India (9%).

How did the research materialize? Who led the knowledge production?

The research was a collaborative exercise for 51% of the presentations with varying levels of inter and intra- country institutional engagement (see figure 2). If co-authors came from multiple institutions, this was considered as institutional collaboration. This mainly involved research and capacity building partnerships. The ‘Nil’ category (49%) consists of studies where all the authors represent only one institution (i.e. no collaboration), with 20% of these in the global North.

Inter-country collaborative research accounted for 32% of the total amount of abstracts, with most coming from North – South collaboration (28%). South – South collaboration in research was abysmally small (less than 2%).

One can explore (and also question) how ‘equal’ these collaborations were in terms of ownership of research. Analysis of the authorship of research in the North-South collaborations revealed that a large share of first authors (47% of the total amount of North – South studies) were based in institutions located in the North, pointing to the still existing hierarchy in global knowledge production (see also Hasnida et al in The Lancet Global Health  (2016)). One might wonder whether the funding modalities that compelled the North to form some of these collaborations also inspired really shared ownership.

There was at least one institution from the global North involved in more than half of the total number of studies on Asia, Africa and Latin America. Also, in one fifth of the number of studies on the South, no collaborating institution from the regions of study was acknowledged by the research institutions (in the North). This is appalling, especially now that we are at a juncture discussing the co-production of knowledge.

Note that neither the questions nor the answers that emerged in the above exercise were new. They simply restate the continuing dominance of the global North in steering much of the research and highlight the ongoing power imbalances in the production of knowledge. Considering the current budget cuts by several governments in the South, we cannot anticipate any reduction in dependence on external funding for research in the medium term. Still, when health systems research is increasingly (and rightly) a multi-country collaborative endeavour, we need due space for discussing the ethics of collaboration and negotiating the power relations. Clearly, not all collaborations are equal. At the very least, when donors put in place North-South collaboration requirements, it is vital they make sure there is true collaboration.