Policy and System Approach (PSA): A primer.

A number of public health challenges have emerged at global and national level in the last two decades. The response to these challenges has rarely been swift and often "knee-jerk." The national and state level program officials responsible for the activities often apportion the blame on weak health systems or fragmented health service delivery mechanisms, amongst other. In India, the viral illnesses (including those due to dengue and chikungunya) are becoming the increasing realities. The Public health response of early identification, disease surveillance, reporting and the preventive and curative measures, remains suboptimal. The health challenges which require multidimensional interventions are usuallyattempted to be resolved through piece meal solutions. This article proposes "policy and system approach (PSA)," combining concepts of "Health in all policies" for intersectoral coordination and "health system approach" for intra-sectoral tackling of the emerging and existing health challenges.

In the year 2015, more than 25,000 cases (and a few deaths) due to dengue fever diseases, were reported from several cities and states in India.[1] Though not the first time dengue cases and deaths in Delhi, India were reported the situation received an unprecedented media attention during the year.[234] As the number of cases climbed up, the immediate response of the governments (both at the center and various state levels) was to allocate more hospital beds and doctors. Very limited efforts were made to prevent breeding of Aedes mosquito which spreads dengue virus and to encourage people to undertake preventive measures. In the following months, as winter arrived, the number of cases went down and everything was forgotten till dengue and chikungunya returned the following year (2016). This is a tragic tale of public health measures and population-level efforts, which have traditionally received insufficient attention in India.[5]

Dengue is spread by Aedes mosquitoes, and like other public health challenges, the responsibility to prevent and control dengue lies with the states and the local health authorities. These efforts include generating awareness regarding the disease, taking measures to prevent mosquito breeding and the spread of dengue, and ensuring availability of health services for those infected. The occurrence of dengue cases in any setting indicates and reflects a lack of timely and sufficient preventive and public health efforts by the local health administration. There could be multitude of reasons for insufficient public health efforts i.e. a lack of role clarity among multiple agencies providing services, insufficient funding, lack of trained and motivated workforce, and more attention on curative care. Hence, when the cases are reported the initial reaction of the health officials is to deny the reports. Year after year, health authorities claim that adequate preventive measures are being taken, yet dengue keeps returning to haunt the poor and rich alike.

The situation is similar for many other diseases. Since 1978, almost every summer, children in Gorakhpur region of eastern Uttar Pradesh and Muzaffarpur in Bihar die due to what was earlier thought to be Japanese encephalitis and is now identified as acute encephalitis syndrome.[6] When cases are reported, under media glare; teams are sent to the affected areas and commitments made. However, policy attention shifts soon after the cases disappear – only to return the following year.

One of the commonly cited reasons for the poor health status in India is insufficient overall spending on health by the union and state governments. The Government's expenditure on health in India ranges from 1.1% to 1.3% of gross domestic product (GDP), which is among one of the lowest in the world (Global average is 6% of GDP on health by government).[7] In India, while experts have strongly recommended raising public expenditure on health in India to 2.5%–3.0% of GDP, it has continued to remain low.[8] While health expenditure is low, the public health measures and preventive and promotive efforts get minimal share of limited funds. The low health expenditure (including only 2% of total health expenditure on public health) in India is reflected in poor disease surveillance, regular disease outbreaks and limited public health measures such as health education, prevention and control of mosquito breeding, community awareness, and so on. These efforts are solely with the government authorities, and the private health sector (which mainly focuses on curative and diagnostic health care) has limited incentives to invest resources in such measures. The limited private sector engagement should be considered a reason for higher government investment on public health. The current investment in India on public health at approx Indian Rupee 100 or US$ 1.6 per capita is extremely low by any standard.

At present, the most prevalent approach to crisis management in the context of disease epidemics/outbreak focuses excessively on treatment through clinical care and hospitals, and the public health functions for prevention of the disease and on-population services receive a limited focus.

In this context, it is proposed that public health challenges require actions both from within health sector through comprehensive approach such as strengthening of health systems[8] as well as coordination among different ministries and departments through Health in All Policies (HiAP)[9] or health in policies of all departments. Within health sector, it needs HSA to ensure that all components of health system be strengthened. In this background, the author proposes that a “policy and system approach (PSA)” is adopted for the operational planning in public health. This requires an improved understanding among the policymakers and program managers about PSA. This article gives an example of PSA approach for dengue prevention and control as a public health measure.

HiAP approach for dengue prevention and control indicates various departments/ministries in a particular setting agree on their roles, assign their responsibilities, develop monitoring and accountability framework, and include the tasks in their specific policy documents. An indicative list of stakeholders in dengue prevention and control and their roles is provided in Box 1.

Box 1

Dengue prevention and control: Health in All Policies (HiAP) approach

The HSA for dengue prevention and control would mean that rather than restricting to curative and diagnostic services, a systematic and concerted strategy is required that would incorporate functions of the health system – services provision, resource creation, financing, and stewardship/governance.[10] How this can work has been explained in Box 2.

Box 2

Dengue prevention and control: Health systems approach

PSA could provide an opportunity for a comprehensive look at (a) role of various departments and institutions and (b) whether all functions of health systems are getting sufficient attention. Through PSA, this could be done in more accountable manner and efficiently. The author is aware that the only evidence of success of this approach is that both of its components (HiAP and HSA) are individually effective. It is likely that these put together would have a synergistic effect. However, the proof of this approach would come from ground-level implementation. The stakeholders and entities are encouraged to adopt this approach for tackling public health challenges in low- and middle-income countries.

This article calls the policy makers and program managers to adopt “Policy and Systems Approach (PSA) to tackle existing and emerging public health challenges. An effective implementation of this PSA would need engagement of stakeholders such as academician & training institutions to develop material and built capacity. The PSA could help in developing conducive polices, ensuring that health systems will be strengthened.

Conclusion

There are public health challenges including the emergence of new viral diseases and epidemics. An appropriate way to handle these challenges is to have coordinated efforts by public health authorities, with focus on all components of the health system and all stakeholders (including nonhealth) having stated policy objectives to improve health. PSA could prove an useful tool and should be given a due consideration in health sector planning.

Disclaimer:

The opinions expressed in this article are solely of the author and should not be attributed to any institution/organization; he has been affiliated in the past or at present.