Implementation, effectiveness and political context of comprehensive primary health care: preliminary findings of a global literature review

Primary health care (PHC) is again high on the international agenda. It was the theme of The World Health Report in 2008, thirty years after the Alma-Ata Declaration, and has been the topic of a series of significant conferences around the world throughout 2008. What have we learnt about its impact in improving population health and health equity? What more do we still need to know? These two questions framed a four-year international research/capacity-building project, “Revitalizing Health for All” (RHFA), funded by the Canadian Global Health Research Initiative, which began in 2007. The findings of a global literature review conducted by this Initiative, and focusing on comprehensive primary health care - and how it has been implemented since Alma Ata are presented. The way in which the political context has affected the comprehensiveness of PHC is considered - along with a series of proposed future PHC research areas.Web of Scienc

A theory of change roadmap for universal health coverage in India

The Theory of Change (ToC) approach is one of the methodologies that the Lancet Citizens' Commission has chosen to build a roadmap to achieving Universal Healthcare (UHC) in India in the next 10 years. The work of the Citizens' Commission is organized around five workstreams: Finance, Human Resources for Health (HRH), Citizens' Engagement, Governance, and Technology. Five ToC workshops were conducted, one for each workstream. Individual workshop outputs were then brought together in two cross-workstream workshops where a sectoral Theory of Change for UHC was derived. Seventy-four participants, drawn from the Commission or invited for their expertise, and representing diverse stakeholders and sectors concerned with UHC, contributed to these workshops. A reimagined healthcare system achieves (1) enhanced transparency, accountability, and responsiveness; (2) improved quality of health services; (3) accessible, comprehensive, connected, and affordable care for all; (4) equitable, people-centered and safe health services; and (5) trust in the health system. For a mixed system like India's, achieving these high ideals will require all actors, public, private and civil society, to collaborate and bring about this transformation. During the consultation, paradigm shifts emerged, which were structural or systemic assumptions that were deemed necessary for the realization of all interventions. Critical points of consensus also emerged from the workshops, such as the need for citizen-centricity, greater efficiency in the use of public finances for health care, shifting to team-based managed care, empowerment of frontline health workers, the appropriate use of technology across all phases of patient care, and moving toward an articulation of positive health and wellbeing. Critical areas of contention that remained related to the role of the private sector, especially around financing and service delivery. Few issues for further consultation and research were noted, such as payment for performance across both public and private sectors, the use of accountability metrics across both public and private sectors, and the strategies for addressing structural barriers to realizing the proposed paradigm shifts. As the ToCs were developed in expert groups, citizens' consultations and consultations with administrative leaders were recommended to refine and ground the ToC, and therefore the roadmap to realize UHC, in people's lived reality

A study of policy process and implementation of the National Tuberculosis Programme in India.

TB, a major public health problem in India since the 1900s, has a current prevalence of 14 million and an estimated annual mortality of 500,000 persons. Nation-wide government sponsored anti-TB public health measures introduced in 1948, developed into the National TB Programme in 1962. Despite gains, implementation gaps between programme goals and performance, over 35 years, have been of a magnitude sufficient to cause concern. This study aimed to understand explanatory factors underlying the implementation gap. A policy analysis approach was adopted, focusing on the policy process and specifically on implementation, at national, state, district and local levels. It undertook a historical review with a two-tiered framework covering the period 1947-97. In the first tier the historical narrative is woven around a framework of context, content, process and actors. The nature of the problem and policy relevant technical dimensions of intervention measures are discussed, as are effects of pharmaceutical policies and financial resource flows on TB policy. The second tier applies a framework of implementation factors to national policy development and implementation at state and district level. Interviews were conducted with TB patients, elected representatives, front-line health workers, doctors, district and state staff, national programme managers, researchers and representatives from international agencies. Documents were reviewed. Thus the study incorporated an integrative bottom-up cum top-down approach. Findings highlight that interests of patients, medical and allied professionals, pharmaceutical and diagnostic industries and the state are interdependent, but often conflictual. Unequal societal relations affect not only the development and transmission of TB, but also the implementation of control programmes, particularly for the impoverished, among whom high levels of indebtedness due to the disease and difficulties accessing private services were noted. Techno-managerial approaches to TB control often mask societal and policy process factors accounting for the implementation gap. The importance of leadership, institutional development, capacity at the patient provider interface and accountability and need for sustained policies were noted, within an affirmative framework embodying social justice and safeguarding the interests of the majority of patients

The People’s Health Movement

The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM. Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.</p

Managing Health at District Level: A Framework for Enhancing Programme Implementation in India

COVID-19 pandemic has brought to the fore the need for a strong health system for the social protection of people and to improve health programme implementation in the coming years. India has made great progress in health over the past 50 years; however, despite the progress made, it is faced with several challenges. While infectious diseases remain an unfinished agenda, chronic non-communicable diseases (NCDs) are rising and are now the leading cause of mortality in the country. This is further compounded by the prevailing inequalities in access to quality health care among population groups including those living in remote rural areas. To achieve Universal Health Coverage and Sustainable Development Goals by 2030, India in 2017 revised its National Health Policy and committed itself to attain the highest possible level of good health and well-being, through preventive and promotive health interventions. While policies are enunciated and plans are formulated, the implementation at ground level is at best tardy and lack lustre As an administrative unit for programme implementation, a district has a key role to play in implementing national programmes and in delivery of basic health services to the people. They are strategically placed to plan, organise and lead efforts meant to deliver primary health care services through better management of existing resources and by fully engaging all relevant stakeholders in contributing towards achievement of national health goals and in responding to a public health emergency such as Covid-19. Planning and managing health problems need an improved and responsive health governance. Strategic planning, monitoring and evaluation require integration and coordination of various health programmes including dealing with health crises, fostering inter-sectoral involvement and engagement of the community as a key actor. Efforts are needed to ensure that services reach the most vulnerable and marginalised sections of the society. Adequate governance support at district level through a whole-of-society approach is essential to bridge the health inequities and ensure equitable access to health services. </jats:p

A scoping review protocol to analyze the role of human resources to deliver comprehensive primary healthcare to achieve universal health coverage in India and other low-and-middle-income countries

A comprehensive primary health care (CPHC) approach to health system strengthening is a means to achieve universal health coverage. In India, comprehensive primary healthcare is adopted in the National Health Policy 2017, the National Health Mission (earlier National Rural Health Mission) since 2005 and in redesigning 150,000 Health and Wellness Centres (2018). A scientific approach to planning and management of human resources for health (HRH) is essential to deliver comprehensive primary healthcare services and to realize Universal Health Coverage (UHC). In this scoping review, we aim to analyze and synthesize the available literature relating to human resources required for the delivery of healthcare services for comprehensive primary care. The evidence available from India will be compared with that from other developing nations to derive practices and lessons that can be implemented in our settings. Main search will be done in PubMed and additional searches carried out in grey literature sources and cross-references from included articles. The results will be analyzed with respect to different service areas of comprehensive primary care