As Indian districts are increasingly finding themselves at the receiving end of new monies flowing in under the National Health Mission, something that
everybody were increasingly pushing for, we find ourselves in a strange predicament, the sheer lack of capacity to spend these new resources. As more and more resources become available, our public health services face a curious gap of not knowing how to make the best use of the new resources as well as the powers that the decentralisation process is bringing. While in some places, it is the lack of money, elsewhere it is the lack of ideas, initiative or leadership that stifles organisational improvement in our government health services.
Increasing calls for decentralising and district and sub-district level decision-making have indeed materialised. But alas, these have not been combined with structural reforms in the way our government health services operate. In the lack of public health cadres and generally apathetic work environment, it is left to those rare public-spirited and self-motivated heroes (the ones that remain after decades of apparently frustrating work in the government) to marshal the crumbling public health services. A pity in days when Indian needs stronger and more robust public provision of care.
These are a few other insights are based on my recent paper included in a special supplement on systems thinking supported by the WHO Alliance for Health Policy and Systems Research. The supplement consists of a collection of articles that apply systems thinking in addressing a given problem. It includes interesting papers on the complexity governing immunisation services in Kerala, learning and sense-making in a complex urban setting in Bangladesh, health system development in rural China, a comparative study of sustainability indicators for health system development in Nepal & Somaliland, advice-seeking behaviour among rural physicians in Pakistan, dual practice and neonatal mortality in Uganda and other applications from Ghana and South Africa.
The supplement containing my paper was the topic of a panel discussion that
included the Honorable Minister of health and family welfare of the Government of Karnataka, U T Khadar. The panel was moderated by David Bishai of the Johns Hopkins Bloomberg School of Public Health. Speaking at the panel, he stressed the need for a greater interaction between researchers and policymakers, especially drawing attention to the huge communication gap between these communities. The increasing use of technical jargon and little effort at demystifying scientific findings both hinder this process and researchers certainly ought to accept a large part of the blame. Public health researchers, more than others have the dual jargon burden of medical mumbo-jumbo combined with the general researcher tendency to mystify methods and results beyond societal comprehension. Hence, my effort at having a Hindi and Kannada version of the abstract along with the paper.
The paper describes an evaluation of a capacity building programme implemented among health managers in Tumkur district of Karnataka. A realist evaluation approach is used to understand why the change (wherever it occurred) occurred in some places and not in others, as is often the case in social programmes.