This discussion theme is in continuance to our first discussion titled ‘Health System in India: Bridging the Gap between Potential and Performance’. To review what others have commented on this subject earlier in the first discussion, visit our Blog.

How can we maximize health returns through strengthening Stewardship and Governance?

1. Issues

1.1. Existing governance and accountability mechanisms focus on inputs rather than outcomes.

1.2. There are insufficient mechanisms and opportunities for interaction between ministries and departments of Health and its determinants, especially the Integrated Child Development Services programme (operates Anganwadi centres), water and sanitation and school education.

1.3. Health programmes are centrally managed, with little flexibility and decentralisation of powers for States. This is reflected in the following examples (i) Approval of State Project Implementation Plans (PIPs) takes place at the Centre, subjecting all State strategies to a prior approval from the Centre. (ii) Mid-term modifications/revisions in State PIPs also require to be approved at the Centre (iii) Decisions such as the monetary incentives to be paid to the Accredited Social Health Activist (ASHA-community health workers) are made at the level of the Empowered Programme Committee and Mission Steering Group, which are Central bodies under the NHM, limiting the ability of States to take local decisions on such matters.

2. Suggestions

2.1. The instrument of Memorandum of Understanding (MoU) may be used to formalize mutual commitments between the Centre and States. Such a mechanism would increase outcome based accountability for States’ actions on system wide reforms.

2.2. The MoU can be subjected to concurrent external evaluation, whose reports can be placed before the Mission Steering Group at the national level and Governing body of the State and District health societies to encourage commitment to reforms.

2.3. Accountability of health service providers may be increased by providing a choice to patients to access services through either public or private sector within models of prepaid care.

2.4. In order to identify and plug leakages in health spending, public spending tracking surveys may be undertaken.

2.5. In order to increase convergence, the Anganwadi centre may be developed as a hub for health service delivery.

2.6. States may be encouraged to observe Village Health, Sanitation and Nutrition Days in complete convergence mode.

2.7. A Health impact assessment cell may be developed that will coordinate the measurement of the health impact of policies and programmes of non-health Departments.

2.8. The Panchayats may be empowered to play a meaningful role in convergence within the social sector.

2.9. The lack of flexibility to States may be addressed by allowing programmatic decisions to be taken at the state level by the Chief Secretary of State Level Sanctioning Committees as in the Rashtriya Krishi Vikas Yojana (RKVY), a national programme for agricultural development.