India has implemented a range of policies in the last decade, addressing issues such as sanitation, hygiene, clean cooking, safe drinking water, air pollution, physical fitness, healthy eating, tobacco control, food security, rural employment security, financial protection from health expenses, strengthening primary healthcare systems, improving maternal and child health, controlling communicable and non-communicable diseases, enhancing the production capacity of healthcare professionals, providing incentives for drugs, vaccines, and devices, launching a digital health mission, promoting affordable generic drugs, reinforcing public health infrastructure, and expanding intensive care facilities in non-metro areas, including improved access to specialists through telemedicine.
The impact of these policies is reflected in various health indicators, yet significant disparities exist between states and even within districts. While the policies are commendable, there is a considerable divergence in the capacities of states and districts to execute them with efficiency and effectiveness. Disparities are notable in the competencies required versus those currently possessed by administrators responsible for implementation, particularly in the realm of health administration.
There are also gaps in resources (financial and human) needed for the successful implementation of these policies and actual resources allocated. It is observed that 20% to 40% of the resources allocated remain unutilized due to weaknesses in public health financial management in states. In addition, an additional 20% to 40% of resources are spent on low-value services, i.e., those consults, tests, drugs, admissions, and procedures that are needed as per evidence-based guidelines. Corrupt practices continue to plague our systems impacting the implementation of the right policies.
Another issue that impacts effective implementation is in the area of policy continuity. Periodic elections and frequent transfers of administrative heads lead to disruptions in policies themselves and the strategies devised by administrative decision-makers. There is a need for institutional mechanisms to safeguard against these disruptions and discontinuities. Indian Administrative Service (IAS) personnel are trained to administer multiple sectors. As each sector is evolving into a complex system, the knowledge of a given sector and the skills needed to administer it are far more than a generalist administrator possesses. There may be a case to groom specialist health administrators amongst the IAS cadre.
India has to invest in “continuous competency development” of the health workforce including health administrative and management workforce to become more efficient and effective in implementing policies thereby transforming health systems and improving the health status of people. Digital technologies can be leveraged in every aspect of systems management to bridge some of the existing gaps. The ability to assess the health status of people, its social, economic, and environmental determinants, its threats, the status of health systems in terms of their infrastructural and people capacities to meet the health needs of people, and the financial hardships being faced by people in accessing essential health needs at district public health leadership and administrative team is a pre-requisite to address the gaps and problems in implementing various programs through a systems approach.
Engaging the private sector and communities is vital for the successful implementation of policies. Their engagement is equally important during the stages of policy formulation for their cooperation during implementation. Coordination with non-health departments and ministries is equally important in implementing other sectoral policies that have a significant impact on the health of people.
Implementing agencies lack the capacities in implementation or operational research to guide to develop iterative strategies and undertake course corrections in operational plans. There is a case to partner with academic institutions and knowledge partners in not only undertaking the research but also in building internal capacities and capabilities to undertake similar research along with instituting robust monitoring, evaluation, and learning systems within the implementing agencies.
In summary, in addition to formulating forward-looking health policies, it is imperative to strengthen the capacities of implementing agencies, more specifically at the levels of the states and the districts. It is a good idea to induct the team personnel after assessing their competencies to implement and undertake pre-induction training programs to ensure success in implementation.