Conversations on Health Policy 2024: Year- end Reflections
By Prof. T. Sundararaman
Originally published at Right to Health Resources. Conversatiopns on health Policy
As 2024 draws to a close, we take the opportunity to re-share the full series of “Conversations on Health Policy” published by the RTH Collective over the course of the year. We also take a moment to reflect on the series as a whole and on the intent and directions with which we undertook the building of this web resource and our hopes for its evolution.
Each of the nineteen conversations listed below addresses some of the major contemporary challenges related to health policies and health systems that come in the way of achieving the Right to Health and Healthcare. We say some rather than one because when it comes to health and healthcare no single, major challenge, no matter how well-defined and delineated is ever discrete. Therefore, we approach each of these challenges as a “problematic,” by which we mean a long-standing problem with many determinants admitting a variety of solutions based on context and the theoretical frameworks and ideologies brought to bear on it.
The dominant ideological stream within health-sector reform tends to view these problematics as inherent to public services. As a result, it follows that the solution lies in privatization or market-based reforms. However, three decades of experience with market-based reforms have shown that such reforms do not work out as theorised and in practice, in most situations, increase inequity. On the other hand, from the perspective of those who defend public services and believe that they should be provided as public goods, these problematics are seen primarily as symptoms of the lack of adequate public investment and accountability measures. From this, follow calls for greater investment, along with better enforcement and accountability within the existing design of public healthcare systems. Yet, over time, public health practitioners who have been struggling with addressing these problems within diverse organisational contexts and institutional fields of power, find that as crucial as public investment is, there is more to the problems involved; it is not simply a case of redoubling or reinforcing an older approach. In fact, the failure to address many of these challenges despite greater investment in public health, and the numerous difficulties in fixing accountability within public systems often ends up fuelling the main argument in favour of market-based reforms. And there we remain stuck.
It is here that the Conversations in Health Policy enters and hopefully offer a way forward. By engaging with persons who bring both deep and diverse experiential and academic knowledge, we try to approach these longstanding and complex challenges with renewed empirical and theoretical rigour and imagination and to discuss and deliberate in detail but with as much conceptual clarity as possible. In each case, we build on the important progress that has been made. For instance, the National Rural Health Mission (NRHM) did call for and attempt a number “architectural corrections,” and significant beginnings were made with reforms related to decentralisation, community engagement, professionalisation, and learning from innovation. Unfortunately, these efforts were largely incomplete and half-hearted. But perhaps even more important, while they generated a new positive momentum and effort, reforms struggled to sustain without an analytical framework for strengthening public health systems within which institutional re-design and change management could be fully understood, engaged and owned at all levels.
The Conversations, therefore, begin with a shared understanding among all of us in the collective that better, more contextually-engaged theorisation is not an academic exercise but is vital for meaningful public deliberation. For those within government and working in public systems, such frameworks—and an analysis of their underlying assumptions—are even more important and need to be widely discussed and debated. Unfortunately, though there are volumes of theory that support market-based reforms, there is much less contemporary theory that supports strengthening health systems as public goods, and even less that is publicly disseminated and discussed. One reason why such alternative theory is scarce is that most theoretical frameworks, emerge largely in western universities, and this relates to the political economy of how knowledge is generated, and gains approval and acceptance. When it comes to our own contexts, best practice and case studies are permissible, but not theoretical development.
The Conversations in Health Policy is a small but committed response to the paucity and possibility of attempting to better theorize these problems in ways which are more consistent with health equity and health rights and developed within and in response to our own diverse contexts and our own public systems, as they actually exist. In the process, we not only arrive at an explanation of why both market-based solutions and business-as-usual are not going to work, but we also offer grounded perspectives on the ways forward. Here, we attempt to re-think and work out a range of social, economic and political arrangements for health and healthcare for all, and in each case we pay attention to the technical and administrative aspects of healthcare and how they relate to each other. We understand health systems are complex adaptive systems and they have to be designed to be learning-adaptive systems to address these problematics.
Unsurprisingly, we have also adapted along the way! The first few “conversations” were constructed as essays, but that limited us to certain types of references and did not provide enough scope for sharing experience and for dialogue. Subsequently, we experimented with formats and became much more explicitly conversational, which we found helped us bring out the issues and complexities more clearly.
The nineteen Conversations include disease-specific programmes, health systems components, global health policy, national health programmes and the problems of measurement. Our metrics tell us that on an average we have a readership of about 5000, largely but not solely within the public health community, as very broadly defined. The feedback has been very positive and has encouraged us to keep at it. However, since many of those who follow these conversations began to access them later in the year and may not have been aware of the earlier conversations, we now circulate a list of all the conversations published so far. We hope this makes access to your topic of interest—and other related topics—much easier.
All these conversations are available on the website https://rthresources.in/ .
The website also has a section on best practices and case studies that could be of interest to those in teaching health policy and systems studies. We look forward to expanding the collection over the next year. The website also has a growing collection of articles on important themes and sub-themes within the area of health policy and health systems studies. The thematic areas section aims to provide curated access to publications and reports relevant to each area. A number of these publications have been authored by members of the collective over their years of work within the system and from their contributions to civil society advocacy for health rights. This collection of papers is also very much a work-in- progress.
All this work is voluntary and done with limited resources. In some of these key issues, we hope we have managed to get a meaningful conversation going and provide fresh insights. We are also very encouraged by numerous follow up conversations we have had with policy decision makers, public health resource persons, and most importantly with students around these issues. Our aspiration for the coming year is even greater participation, with more contributions on a wider range of themes, more follow-up conversations, and deeper deliberations on health policy, accessible to all.