Send a ‘good camel’ to the tent: Health system responsiveness to advance universal health coverageC Lahariya
National Professional Officer- Health Care, Access and Protection, World Health Organization Country Office for India, New Delhi, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_600_20
Source of Support: None, Conflict of Interest: None
A health system consists of all organizations, people, and institutions producing actions whose primary intent is to promote, restore, or maintain health. Every health system has goals which are widely agreed: improving health outcomes and equity, financial risk protection, responsiveness and improving efficiency [Figure 1].,, Arguably, of all the health system goals, responsiveness is the least discussed and possibly insufficiently understood as well. Responsiveness is 'the degree to which the legitimate non-medical expectations of people are met through health systems'. The responsive health systems harness opportunities to promote access to effective interventions and anticipate & adapt to changing medical and non-medical needs of populace which they intend to serve, ultimately resulting in the improved health outcomes.,, At times, 'patient satisfaction' is used inter-changeably with responsiveness; while two are linked but not the same. Patient satisfaction focuses on interactions at facilities for care-seeking related aspects while responsiveness deals with a broad range of interactions people have with the system as well as the related non-medical needs.
One of the first and most widely used framework on responsiveness was proposed by the World Health Organization (WHO) and comprises of elements such as dignity, autonomy, confidentiality, prompt attention, quality of amenities, access to social support networks and choice of service provider.,,, Thereafter, a few more frameworks have been developed with additional elements such as doctor-patient communication; patient involvement in treatment decisions and in selection of providers; ease of access to facility; provider accountability, trust and coordination and the environment at clinic/facility.
Conceptually, health systems responsiveness includes two aspects: (a) the initial expectations from health systems actors (service providers and others such as managers and policy-makers) on how the individuals should be treated, and (b) the act of interaction itself – entailing the enactment of the multiple moments and processes of interaction between the people and the health system-shaping people's experiences of these interactions. The most commonly accepted elements of responsiveness, with indicative list of questions to elicit answers to these elements, are listed in [Box 1].
Soon after the World Health Report 2000, which proposed health system framework with one of the goals being responsiveness, a WHO-led and coordinated World Health Survey (WHS) in 71 countries including India, collected data on selected aspects of responsiveness. Thereafter, many countries followed suit and conducted additional surveys with questions on both patient satisfaction as well as on responsiveness., India included some of the questions on responsiveness in demographic, health and facility surveys such as District Level Household surveys (DLHS) and National Family Health Surveys (NFHS). However, the scope of data collected on responsiveness, in most of these surveys remained very limited. The use of such data for actions has, arguably, remained even restricted.
This issue of journal has published an article which focuses upon respectful maternity care during childbirth in India. The study reports that experience of dis-respectful maternity care is more prevalent than respectful care and some of the challenges reported are: non-consent; verbal and physical abuse; and threats and discrimination, amongst other. These findings should make anyone to sit down and take notice as Indian health care system has traditionally developed and designed for maternal and child healthcare services, which are more commonly available than health services for any other sub-group of population of disease condition. Therefore, if this is the situation in maternity care, there is a little reason to believe that other health services would be any better in responsiveness. Interestingly, all studies meeting the inclusion criteria in this systematic review were from two states of India and the earliest study was for the year 2016. Though this could be due to the study design which focused on maternity care during child birth, there is definitive need for more research and documentation on responsiveness of health services for a wider range of services and settings.
The consent, respectful care, non-discrimination and fairness are some of the most important qualities of a responsive health system. These at times, may appear abstract to many; however, each of these matters a lot for the patients and people. The responsiveness in mother and child health services can be considered as 'thermometer of responsiveness' for a health system, as a whole. A majority of Indian populace, especially the poor and underserved, depends on the government facilities for health care needs. These are the people who are voiceless and nearly always fails to demand for better health services. Health care for poor should not end up becoming poor health care. Therefore, developing mechanism to capture their expectations and non-medical needs from health services and use of this information for corrective measures, should be given due importance in policy-making and program design. All health systems, Indian health care system being no exception, need to have better understanding of responsiveness, by different sub-groups: public and private sector, from level of care to type of care (in-patient and outpatient) as well as by states and equity perspective. Understanding populations' perceptions is critical to devise mechanisms to increase the utilization of health care services. This is highly desirable as India has committed to accelerated progress towards UHC.
A plausible explanation why there is not enough research and documentation on responsiveness of health services in India could be that, for many years, the immediate focus had been on increasing the access and provision of health services. Even today, responsiveness has either not been fully understood or is considered to be addressed at a later stage. A decade ago, almost similar situation existed for discourse on quality of health care services. In immediate period after launch of the National Rural Health Mission (NRHM) in India, the focus was on improving access and availability of health services, with limited attention on quality of services. For long, many activities in health systems strengthening were considered to be done in a series- first do one and then plan for the next till all would be done. However, with such an approach, often the initial few interventions get attention and rest are partially implemented in a delayed manner. Fortunately, now there is near-consensus that interventions to improve quality of health services should be part of process of increasing access and availability, from the very beginning. That is true for all functions, intermediate goals and final goals (including responsiveness) of the health system [Figure 1]. In short, all health system strengthening activities need to be done in parallel, without waiting for one to be completed and then doing next. Having not received sufficient attention earlier, responsiveness unarguably requires urgent attention.
Emerging evidence from Mohalla or community clinics of Delhi highlights that it is the responsiveness and fulfilling non-medical needs of people that results in increasing use and return visits to the government health facilities. The ongoing discourse on strengthening primary health care system in India through health and wellness centres (HWCs) under Ayushman Bharat Program, as well as initiatives under national health mission should be optimally used to re-work and refocus towards improving responsiveness of health systems in India. The facility surveys, which have not been conducted lately, need to be re-started with comprehensive questionnaires on responsiveness. Furthermore, there is a need to have more studies by individual researchers and academic institutions. More importantly, the information generated through such surveys and studies should be regularly used for corrective actions and interventions., In addition, the mechanisms for social accountability and community participation can help improving health system responsiveness and approaches need to be institutionalized. There is also a felt need for public health teaching and training institutions in India to develop and conduct short training programs on health system responsiveness as part of overall health system strengthening initiatives.
Clearly, responsiveness is about the way and the environment in which individuals are treated during an interaction with a health system. In early 2020, during the Corona Virus Disease -19 (COVID-19) pandemic in India, many issues related to responsiveness emerged. There were reports that access to health services was severely reduced due to a partial closure of many facilities and the lockdown which resulted in reduced availability of public transport. The insufficient communication and public awareness resulted with people having to visit multiple facilities before receiving the health services they needed. There were reports of patient identities being revealed (confidentiality not maintained) and stigmatization and discrimination of people affected by COVID-19. Though, the ongoing COVID-19 pandemic of 2020 is an extraordinary situation; the responsiveness of a health system in routine determines what happens during special and unprecedented situations such as COVID-19 pandemic. The pressure and load on health system during the pandemic had apparently amplified what has been the common challenges in health system responsiveness. Within a few weeks of onset of the pandemic, the approach to patient confidentiality, access to and provision of essential non-COVID-19 services, communication, addressing discrimination and tackling mental health issues was far better than at the beginning of the pandemic. Some of the early lessons from tackling COVID-19 pandemic also underscores the importance of health system responsiveness for effective response to the pandemic. It would be desirable that in the time ahead, the learnings from the current COVID-19 pandemic are used for improving health system responsiveness for other aspects of health system strengthening in India.
It is nearly two decades since the first discourse on health system responsiveness started. At present, there is a global discourse on UHC. The opportunity provided by ongoing UHC discourse, where nearly all countries are taking some actions, should be used for bringing attention on responsiveness. Doing so can increase access and utilization of health services and can also help to achieve the other 3 health system goals of improving health (outcome and equity), financial risk protection and improving efficiency. Whichever way we look at it, the time has come that health system responsiveness gets due attention to advance UHC.
Author is the staff member of the World Health Organization (WHO). The views expressed in this article are personal, and do not necessarily represent the decisions, policy, or views of organizations/institutions, the author has been affiliated in past or at present.