Introduction

The COVID-19 pandemic has brought to light the importance of not only improving the resilience of health systems to crises but also of ensuring their long-term sustainability. The Partnership for Health System Sustainability and Resilience (PHSSR) was established in 2020 with the goal of building more sustainable and resilient health systems around the world.

One of the key objectives of PHSSR is to build knowledge, understanding, and consensus on the dimensions of health system sustainability and resilience, and how they can be improved. To achieve this goal, PHSSR focuses on seven key domains:

• Governance: the wide range of steering and rule-making related functions carried out by governments and decision-makers as they seek to achieve national health policy objectives.
• Financing: how health systems generate, pool, and allocate financial resources and pay for health services.
• Workforce: how health systems plan for, train, recruit, reward, and deploy their workforce, and shape the conditions in which health professionals work.
• Medicines and Technology: how health systems make use of medicines and (information) technologies in the delivery of health services.
• Service Delivery: how health services are organised and delivered, including ambulatory and hospital care, and public health.
• Population Health: how health systems address the social determinants of health and meet the needs and demands of the population.
• Environmental Sustainability: how health systems prevent and minimise their carbon footprint and the impacts of pollution on the population’s health.

By examining each of these domains, PHSSR seeks to identify strengths, weaknesses, opportunities, and threats to health systems and to generate evidence-informed solutions and policy recommendations to improve sustainability and resilience.

A sustainable health system improves population health by continually delivering the key functions of providing services, generating resources, financing, and stewardship, incorporating principles of financial fairness, equity in access, responsiveness, and efficiency of care, and does so in an environmentally sustainable manner.

A resilient health system is able to prevent, respond to, manage the health system impact of, and recover and learn from, acute and chronic crises (including, but not limited to, pandemic threats, climate change, and economic and technological shocks), minimising their short-and long-term impacts on health, social and economic wellbeing.

The COVID-19 pandemic has undeniably tested the Indian health system, presenting unprecedented challenges and highlighting opportunities for growth. PHSSR and Observer Research Foundation's research across seven key domains provides a holistic assessment of the system's response to the pandemic and its underlying strengths and weaknesses, pinpointing areas for improvement to bolster long-term sustainability and resilience, including preliminary recommendations for reform and policy focus. The report draws on recent data, health policy literature, and interviews with diverse stakeholders, aiming to provide a balanced and constructive assessment.

India's health system has historically been characterised by a strong private sector, which has made significant advancements in healthcare provision by comparison to the relatively under-developed public sector. However, this has also resulted in high out-of-pocket payments, necessitating a focus on affordability and accessibility. In response, the last decade has witnessed an encouraging shift towards public provision, with significant initiatives aimed at ensuring quality care and reducing the cost of medicines. This evolution reflects the system's capacity for adaptation and progress.

In the domain of governance, the report notes that the Indian health system has a complex and decentralised structure, with varying levels of capacity and coordination across different states and territories. While the complexity of India’s health system creates challenges of coordination at a national level, it also allows for innovation and experimentation at the local level.

Financially, the country has made notable strides in enhancing protection for the economically disadvantaged and reducing out-of-pocket expenditure. Continued public investment and efficient resource utilisation are crucial in maintaining this positive momentum towards financial inclusivity in healthcare.

The chapter on India’s healthcare workforce acknowledges the critical need for more skilled health workers, especially in underserved rural areas. Enhancing training and support for frontline workers is paramount in strengthening the backbone of India's healthcare.

In terms of medicines and technology, the focus remains on enhancing regulation and quality control to ensure the availability and affordability of essential medicines and the safety of medical devices, while underlining the undoubted strength of India’s pharmaceuticals and medical technology sectors. Similarly, the chapter on service delivery notes remarkable progress in access to quality care in recent times, while calling for sustained focus on addressing gaps, particularly for those in rural settings and marginalised communities.

The population health domain describes a multitude of initiatives to protect and uphold public health, but highlights the need for a more comprehensive and joined-up approach, including greater investment in disease prevention and health promotion.

The report also explores environmental sustainability, highlighting the importance of ensuring that India’s health system is sustainable in the face of climate change and other environmental challenges. This includes reducing the environmental impact of healthcare practices, ensuring that health services adapt to changing needs and also addressing social determinants of health that increase people’s exposure and vulnerability to environmental risks.

Finally, the report includes two detailed case studies, focusing on two key health schemes in India’s journey to universal health coverage: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP). These case studies underscore significant progress in addressing critical gaps in public health insurance coverage, and ensuring access to medicines and technologies, respectively. Such major initiatives highlight the potential for positive change when ambitions are met with careful policy design and implementation, commensurate resources, and sustained political will.

This report is ORF’s contribution to the global collaboration, Partnership for Health System Sustainability and Resilience. It was first published on 15 February 2024, and can be found here: WEF_PHSSR_India_2024.pdf (weforum.org)

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Read the entire report here.

• Healthcare
• India
• Ayushman Bharat
• Climate change
• Covid-19
• environmental sustainability
• financing
• governance
• health systems
• India
• medicines
• PHSSR
• population health
• Regulation
• resilience
• rural healthcare
• service delivery
• Sustainability
• Technology
• workforce

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