Health System

Semester and Year Offered: 1st Semester, 1st Year

Course Coordinator and Team:

Email of course coordinator:

Pre-requisites: None

Aim: The health system of a country is a complex construct, critically determined by history, contexts and social, political and economic realities of a nation. Thus a comprehensive understanding of the same, must ideally go beyond the six building blocks of a health system, as proposed by the WHO - service delivery, health workforce, information, medical supplies, vaccines and technologies, financing, and leadership/governance. This course therefore will start with a discussion on ‘health system’ and ‘systems thinking’ as concepts and their relevance. It will move on to critically discuss different models of health system proposed in the literature.

This course will then, introduce students to the specifics of the Indian health system, as well as the relevant issues and concerns around key aspects of the Indian health system like levels of care, systems of medicine, medical education, health workforce, infrastructure and services, financing and governance. The course will encompass the full continuum between public health (population-based services) and medical care (delivered to individual patients) with a continuous effort to characterize the distinction and the tension between the two.

Course Outcomes:

• Understanding health system goals and the principles underlying them.
• A systems thinking approach to understanding health systems around the world.
• Appreciation of the complexities of the health system in India
• Understanding the role of each and every component in securing health of the population in India.
• Familiarity with framework(s) for health system performance assessments in the backdrop of their stated goals and principles

Brief description of modules/ Main modules:

• Health system goals and principles:This module introduces students to the goals of a health system and their underlying normative principles. The goals or outcomes of a health system generally are good physical and mental health, financial protection, access, and quality of care. The values and principles underlying a nation’s health system could be right to health, choice, equity, autonomy, efficiency, participation, trust, accountability and others. An understanding of the goals and principles of a health system at the outset, should enable the students to develop a critical perspective towards each component of the current health system.
• Health Service Delivery: This module introduces health service delivery with a focus on both public health services as well as health care. The key topics to be covered are concepts of preventive, promotive, curative and rehabilitative health, levels of health care – primary, secondary and tertiary and the referral system, and systems of medicine. This would also introduce students to public health services like immunization, vaccination, family planning , behavioural counseling and services covering the entire spectrum of health and wellbeing, not only the eradication of particular diseases. Aspects of equity and quality of health services will form a significant part of this module. Selected contemporary issues like medical tourism and its impact on the health system will also be introduced.
• Governance and leadership: This module introduces students to the roles and responsibilities of different tiers of Government, the private sector, the non-governmental sector and public-private partnerships in delivering key public health functions and health care services, in the backdrop of the evolving political economic landscape of India.
• Financing: This module will provide an overview of health financing arrangements in India. The idea is to explore the role of composition of health finances in alignment or deviations from the stated goals and values underlying the Indian health system.
• Infrastructure: This module focuses on health infrastructure in India. The module would introduce students to the Indian Public Health Standards (IPHS) guidelines and norms, systems of medicine and the issues of equity and quality of services.
• Human resource: This module covers another key component of the health system – human resources. In addition to the salient features of human resources for health in India, the course aims for a critical understanding of issues around human resources for health like rural postings, internal and international migration of qualified workforce, lack of public health education, monetary and non-monetary incentives and characteristics of medical education in the country.
• Medical products, vaccines and technology: This module covers medical supplies, vaccines and technologies as a component of the health system. The module will unravel the intricacies of the political, economic, legal, technical and ethical issues around access to medical supplies and technology, and their implications for health equity.
• Knowledge and information: Health information systems are critical to health systems, especially in the prevention of the spread of communicable diseases. This module discusses the prospects of knowledge and information in public health and health care. It also explores resources, devices, systems and institutions required for the attainment, storage and utilization of knowledge and information in the public health sphere.
• Health system assessments: This module introduces students to the concept of health system strengthening and the different conceptual frameworks available, to analyze health system performance. Being the final module of this course, the students are now expected to be familiar with the building blocks of the health system. So this module will also return to the concept of systems thinking in public health.

Assessment Details with weights:

• Examination (30%).
• Term paper and presentation (40%).
• Field based activity and report (30%).

Reading List:

• Lee, L.M., Zarowsky, C. Foundational values for public health. Public Health Rev 36, 2 (2015). https://doi.org/10.1186/s40985-015-0004-1
• Roemer, MI., "National Health Systems throughout The World" Annu. Rev. Publ. Health 1993. 14:335-53
• World Health Organisation, "Chapter one: Why do health systems matter?" The World Health Report 2000: Health Systems: Improving Performance, 2000;1-19.
• Tanahashi T (1978) Health service coverage and its evaluation. Bulletin of the World Health Organization 56(2), 295-303.
• Donabedian, A. (1966). Evaluating the Quality of Medical Care. The Milibank Quarterly. Vol. 44, No. 3, Pt. 2, 1966 (pp. 166-203)
• Baruet. al. (2010). Inequities in Access to Health Services in India: Caste, Class and Region. Economic and Political Weekly, 2010, Vol. 45, No. 38, pp. 49-58
• Sengupta, A (2011). Medical Tourism: Reverse Subsidy for the Elite. Signs , Vol. 36, No. 2 (Winter 2011), pp. 312-319
• Sen, G. (2012). Universal Health Coverage in India: A Long and Winding Road. Economic and Political Weekly , Vol. 47, No. 8 , pp. 45-52
• Priya, R. 2012. 'AYUSH and Public Health: Democratic Pluralism and the Quality of Health Services', in Sujatha, V. & L. Abraham (eds.) Medical Pluralism in Contemporary India, Orient Blackswan, pp.103-12
• Health in the Indian Constitution, K. RaghavendraRao and P.R. Panchamukhi, CMDR Monograph Series No. - 7. Centre for Multi-Disciplinary Development Research, Dharwad
• Lakshminarayanan S. (2011). Role of government in public health: Current scenario in India and future scope. Journal of family & community medicine, 18(1), 26-30.
• Dasgupta, M (2005): Public Health in India: Dangerous Neglect. Economic and Political Weekly, Vol. 40, No. 49 (Dec. 3-9, 2005), pp. 5159-5165
• Baru, R &Nundy, M (2008). Blurring of Boundaries: Public-Private Partnerships in Health Services in India, Economic and Political Weekly ,2008, Vol. 43, No. 4 (Jan. 26 - Feb. 1, 2008), pp. 62-71
• National Health Accounts, Government of India, 2019
• Indian Public Health Standards for SC's, PHC's, CHC's, sub-district hospitals and district hospitals
• Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet. 2011 Feb 12;377(9765):587-98. doi: 10.1016/S0140-6736(10)61888-0. Epub 2011 Jan 10. PMID: 21227499.
• Joshi, S. R. and M. George (2012) 'Healthcare through community participation: role of ASHAs', Economic and Political Weekly, 47(10): 70-6.
• Jacob, K.S. (2016). Politics of Medical Education in India. Economic and Political Weekly, Vol. 51, Issue No. 12, 19 Mar, 2016
• Frenk, J. (1993), "The Public-Private Mix and Human Resources for Health", Health Policy and Planning, 8: 315-326
• Ramakumar, R. (2021). Politics and Economics of Vaccine Policy, Economic and Political Weekly, Vol. 56, Issue No. 18, 01 May, 2021.
• Access to Medicines, Vaccines and Technology, Chapter 3, High Level Expert Group (HLEG) Report on Universal Health Coverage, GOI, 2011
• AbouZahr, C &Boerma T (2005). Health information systems: the foundations of public health. Bulletin of the World Health Organization, | August 2005, 83 (8)
• vanOlmen, J., Marchal, B., Van Damme, W. et al. Health systems frameworks in their political context: framing divergent agendas. BMC Public Health 12, 774 (2012)
• RifatAtun, Health systems, systems thinking and innovation, Health Policy and Planning, Volume 27, Issue suppl_4, October 2012, Pages iv4-iv8, https://doi.org/10.1093/heapol/czs088
• Winslow, C.E.A. (1920). The Untilled Fields of Public Health. Science , Jan. 9, 1920, New Series, Vol. 51, No. 1306 (Jan. 9, 1920), pp. 23-33
• Krishna D Rao, SudhaRamani, IndrajitHazarika, Sunil George, When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India, Health Policy and Planning, Volume 29, Issue 4, July 2014, Pages 495-505
• Arden Handler, Michele Issel, and Bernard Turnock, 2001: A Conceptual Framework to Measure Performance of the Public Health System American Journal of Public Health 91, 1235_1239