Sometimes, the more things change, the more they remain the same. This is particularly true of India’s health sector where in the past decade important public investments have been made, yet, it seems like little has changed. Two major developments have characterized India’s health system in the past ten years, which in many ways marked a new era for the health sector. The first was the launch of the National Rural Health Mission (NRHM) in 2005, renewed now as the National Health Mission, to strengthen the public sector health system, particularly for primary care. Through the NRHM large investments were made in strengthening service delivery in the public sector, a national conditional cash transfer program for institutional deliveries was established, as well as a community health worker program which saw the introduction of over 9,07,918 community workers across the country. The second development was the spread of government sponsored insurance schemes covering hospital care for the poor. These schemes have rapidly expanded; the national health insurance scheme, the Rashtriya Swasthya Bima Yojana (RSBY), now covers most of India and several states have their own schemes. It is estimated that, by 2015, half of India’s population will be covered by government insurance schemes. Many believe that these new initiatives can move India closer to Universal Health Coverage. Yet, as recent news reports tell us, India’s health system continues to grapple with the delivery of basic preventive and curative health services. The repeated outbreaks of dengue in the national capital and elsewhere, for example, and the inability of the health system to prevent and respond to it are symptoms. Moreover, public health spending on health remains low at 1% of GDP; national surveys continue to report on the high levels of out-of-pocket payments and the related fall into poverty that often goes with it.
In the context of these health system reforms, it is important to ask: what has been the response of the health systems research community, and in what ways can health systems research contribute to strengthening the reforms currently underway in India? All signs indicate that there is a growing Indian interest in health systems research. At the institutional level, the National Health Systems Resource Centers, and its affiliate State Health Resource Centers, were established under NRHM to provide research and technical assistance to the Ministry of Health and Family Welfare, and the NRHM. In 2007, two years after the start of the NRHM, the Department of Health Research was established with a mandate to improve research both in the public and clinical aspects of health care. The government sponsored insurance schemes also put emphasis on research. For instance, the Aarogyasri Health Care Trust, which implements the Rajiv Aarogyasri health insurance scheme in Andhra Pradesh, has an embedded research unit.
Research on health systems in India has broadly followed the shifting patterns of both national and global health policies. For instance, in the decades following Independence, various committee reports and national health policies, as well as research on health systems, mirrored the government’s preoccupation with expanding coverage of health services, including human resources. A recent review on health systems research in India during the reform period of 2005-2013 is revealing about the current state of health systems research. The study found that the number of publications on health systems progressively increased every year from 92 in 2006 to 314 in 2012. The majority of papers were on service delivery (40%), with fewer on information (16%), medical technology and vaccines (15%), human resources (11%), governance (5%), and financing (8%). The lack of research on issues like health care financing, human resources, and governance is remarkable given the nature of health reforms in India – in the context of low public spending on health, scarce human resources, and weak systems of governance. The review also found that around 70% of articles were lead by an author based in India, which shows the strength of the domestic research capacity. However, the majority of authors were located in only four states. Indeed, several states, particularly in eastern and north-eastern India, did not have a single paper published by a lead author located in a local institution. Moreover, many of these states were not the subject of a single published paper. It is important, therefore, that health systems research in the future also focuses on strengthening health systems research capacity in states and institutions that have a scarcity of researchers, as well as states that have been the focus of little research. While more funding for health systems research is required, this funding needs to be targeted at deficient health systems domains, geographical areas, and institutions.
Strengthening public accountability is another function of health systems research that requires emphasis in the road ahead. Health systems researchers have the important function of being observers, perhaps even watchdogs, of India’s health system reform efforts. Research on program implementation and policy has the important function of creating a culture of public accountability, in addition to increasing our knowledge of program performance. The accountability function of health systems research is surprisingly understated. Whenever a researcher studies a program, collects data, analyzes and disseminates it, he or she is acting as an independent observer and reporter of the program’s functioning. Asking questions about the state of a program’s functioning, if it has had an impact on its objectives, and if it served the poor or not – are all profoundly powerful acts of promoting accountability. The more such research is produced, the greater will be the pressure of public accountability on public functionaries to improve performance. In the era of health systems reforms, health system researchers in India have the additional responsibility of strengthening public accountability through their research.