Shibu Vijayan, Sapna Naveen, Nitya Rachel George, Bobby John, Muhammed Shaffi, Gopukrishan Pillai
a. Global Health Advocates India, New Delhi, India
b. Program for Appropriate Technology in Health (PATH), New Delhi, India
c. Global Institute of Public Health, Ananthapuri Hospitals, Trivandrum, Kerala, India
Identifying factors that contribute the most towards meeting the healthcare needs of the population is of particular importance in a developing country such as India. Good governance in health should lead to provision of healthcare of acceptable quality that is physically and socially accessible to all segments of the population. It should moreover be delivered in culturally acceptable forms, without injuring basic human dignity or otherwise offending local customs. Allocation of scarce economic resouces between different groups and for different purposes is often the negotiated outcome of a complicated political process. Quality of public health is ultimately contingent on the quality of governance in a country. Recent changes in allocation of resources for health bring this fact to plain light. This study is an attempt to compile the grassroots perspective on health systems performance and the role of local self governements in improving the same.
The study was performed in different regions on Rajasthan using mixed methodology approach. The methods included multi-state holder discussions, focus group discussion and surveys. This study highlights the multiplicity of factors that could raise barriers to healthcare access. These range from such obvious ones as lack of infrastructure or large distances, to such elements as information barriers, cultural outlooks etc that tend to be overlooked in many cases. The study findings reiterates the inter-connectedness of the numerous medical and non-medical determinants. Managing the multiplicity of factors and their numerous interactions will have to be streamlined by an appropriate program that combines the local context with the national scene.
It is well documented that some countries achieve better health outcomes than do others at similar levels of income.1, 2 Identifying those factors that contribute the most towards meeting the healthcare needs of the population is of particular importance in a developing country such as India, where the health indices remain poor compounded by a very low spending on health by the Government.3 It is inescapable that not only has India not managed to improve its healthcare indices vis-a-vis the developed nations, but fares poorly even when compared with some of its neighbouring coutries in South Asia even as it has fared much better in achieving overall economic growth.4
Despite overall improvement in the capabilities of the state, functionality and accessibility of the health amenities available to the population remains unsatisfactory on the whole. The paradoxical situation, wherein worsening or stagnating health indices persist even as the state’s ability to allocate resources is improving, warrants further exploration. Allocation of scarce economic resouces between different groups and for different purposes is often the negotiated outcome of a complicated political process. It is in this light that the philosophical assumptions of the government of the day become an important determinant of the standard of healthcare as distinct from the quality of administration delivered by its functionaries. Thus, quality of public health is ultimately contingent on the quality of governance in a country.5 Recent changes in allocation of resources for health bring this fact to plain light.
Good governance in health should lead to provision of healthcare of acceptable quality that is physically and socially accessible to all segments of the population. It should moreover be delivered in culturally acceptable forms, without injuring basic human dignity or otherwise offending local customs. Finally, effective bureaucracies should not only be able to innovate and adapt to resource limitations, but also learn from experience thereby building up institutional memories.2
Currently few documented evidences are available which gives an understanding of the community perceptions around the health system performance and the extent of engagement of the Local Self Government Institutions (LSGIs)- the Panchayati Raj Institutions (PRIs) and other community Systems like Village Health Sanitation and Nutrition Committee (VHSNC) in health apart from Common Review Mission (CRM)i documents under National Rural Health Mission (NRHM).6,ii This study by Global Health Advocates (GHA) India along with their Non Governmental Organization (NGO)/Civil Society partners is an attempt to compile the grassroots perspective on health systems performance and the role of local self governments in improving the same.
The study tried to understand the factors which affect the functionality of the health systems and to know the stakeholders perspectives on what role can LSGIs play in improving the health systems performance.
Materials and Methods
The study was performed in different regions on Rajasthaniii using mixed methodology approach. The methods included multi-state holder discussions, focus group discussion and surveys. Multi-stake holder discussions were conducted in six districts (Alwar, Jaipur, Jaisalmer, Jodhpur, Sirohi and Udaipur) to identify gaps leading to low performance in delivering healthcare, and potential solutions for the same. Consultations were held with multiple stakeholder groups (table 1) such as district health officials, members of NGOs working in health and development and in civil society organizations, local self- government representatives, community leaders and members of the media. In the course of this discussion, many gaps were identified that hinder the health care delivery available to the populations.
Focus group discussions were held with PRI members of Abu road to assess their perceptions on health and their involvement in health. Survey of VHSNC members to assess the functionality of the VHSNC was carried out in 30 VHSNCs spread across 30 villages of five blocks in Jodhpur. The period of the study was from September 2012 to February 2013 and it involved multiple partners (table 2).
Multi stake holder discussions revealed many factors that impact the functionality of the health system, thereby determining the community’s ability to avail of healthcare.
First and foremost was the shortage of human resources that was noted at many institutions, with insufficient medical officers at Primary Health Centers (PHCs), absence of Auxiliary Nurse Midwives (ANMs) at sub-centers, and staff at Directly Observed Treatment, Short-course (DOTS) centers. It was mentioned that only one paediatrician exists for a population of 10.6 lakhs, in the Sirohi district. Gaps in health infrastructure were noted in all districts, with an inadequate number of sub-centers available in regard to population norms. The under utilization of existing infrastructure is also a major contributor to poor health service delivery among the districts of Rajasthan. Anganwadi and malnutrition centers were reported as not functioning properly. Most of the sub-centers are only being used for immunization, while PHCs and Community Health Centers (CHCs) are experiencing overloading despite the inadequacy of staff to handle emergencies. Women in the community reported that cleanliness is also a major concern among health facilities in the area, with bathrooms and toilets often left uncleaned, or remaining locked, blocking access altogether.
With regard to the existence of appropriate infrastructure to respond to conditions that contribute to the population’s morbidity, findings may be summarised as follows. Facilities to conduct differential diagnoses of Tuberculosis (TB), silicosis and asbestosis are not available in many districts within which these conditions are prevalent. DOTS centers and sputum testing centers were reported as being unreachable by those in need, in most districts. A trial site for the management of silicosis has been planned, but not yet implemented in Jodhpur. An absence of blood storage units, raises the risk of postpartum complications such as such as hemorrhage, leading to death or permanent health impairment among women. The lack of vaccine transportation, cold chain maintenance, as well as backup electricity during power cuts, also contribute to the health care available to individuals requirement for illnesses, as well as reproductive complications.
Irregular finances and fund flow have also been attributed to the inadequacy and poor functionality of the health system. Delays in vaccinations have been seen as the funds for outreach have been low. Malnutrition centers have also experienced delays and inadequacies in receiving funds for their activities. Due to under-utilization of funds by the VHSNC over the past three years, the untied funds have been reduced to Indian Rupee (INR) 5,000 from INR 10,000.
Physical and geographical barriers to access exist as well, in terms of distance and transport available to places of healthcare. Low access to local diagnostic facilities requires people to travel to district medical centers and medical colleges, leading to delays in diagnosis and discontinuation of treatment. Populations living in remote locations, have particular trouble in accessing DOTs centers for sputum testing, TB diagnosis and Multidrug-resistant TB (MDR-TB) case testing. Especially inaccessible and remote high tribal population areas, face these problems to an even greater extent. It was also found that ten ambulances were introduced in Sirohi and Reodar regions by the local Member of Parliament (MP) to address these issues. Network connectivity problems also hinder access to transport services that are available to the population through government schemes, such as the 108 ambulance service.iv Inability to transport women in labour to medical facilities in time, has resulted in a range of maternal and infant health complications.
Social and information barriers to accessing healthcare were also highlighted during the consultations. It was reported that the community was largely unaware of the VHSNC, with an overall lack of social empowerment. Although some members of the population are aware of government schemes, it was reported that they did not have enough knowledge about them to really benefit from them. To address the information gap, a workshop was organized by the government on health services and schemes available in rural areas, with as special focus on those available for maternal and child care in Sirohi. It was also recommended that VHSNC meetings should take place regularly, encouraging increased attendance. Although information is low, community engagement was seen to be strong in most districts, especially Udaipur and Sirohi. Vocal and receptive community representatives, with a moderate understanding of the health system and issues to be addressed, are missing a platform where community opinions can be expressed and change can be demanded. With regard to local self government, involvement of PRIs in health is variable, with largely sub optimal involvement by the PRIs reported across all the stakeholder discussions. The majority of the participants recognized that PRIs do have a key role in planning implementing and overseeing the health programs.
Economic and cultural outlooks too can significantly influenze the way health care is availed of. For instance, time spent in a health facility is often perceived as time spent away from the household and livelihood opportunities. For this reason, women do not stay at hospitals for Post Natal Care (PNC) and leave immediately after delivery, raising the risk of complications, which cannot be addressed in the home setting. In their hurry to return to the household, families have been seen to demand the administration of oxytocin to induce labour, leading to maternal and child morbidity and mortality. This practice, in turn, also reflects upon the knowledge and decision making ability of staff at health facilities. In addition to this, the custom of early marriages is still prevalent in the community, with villagers claiming that as much as 80% of marriages are conducted in this manner. Early child bearing too, is commonplace, and has serious health implications for the mother, and the family as a whole.
Morbidity conditions, and response to illnesses are determined, by how the aforementioned characteristics of the health system react to each other. Poor nutrition has been a complaint across all districts, leading to conditions such as anaemia. Illnesses such as silicosis and asbestosis are prevalent among communities in mining and quarrying areas, without much opportunity for diagnosis or treatment. TB cases have been seen to be linked with infertility. The poor nutrition- anemia link is seen to have long lasting impacts, with 39% of children being born underweight. Malnutrition treatment centers, known as Nutrition Rehabilitation Centers (NRCs) are often underutilized. Many members of the community are not aware of the nutrition component that has been added to the VHSNC, to tackle many of these problems. Suggestions to involve NGOs to manage the NRCs were placed.
With regard to reproductive health, Ante Natal Care (ANC) was reported to be weak among the studied districts. Track records are not maintained for anaemic mothers and pregnant women. Only 30% of births in Jaisalmer take place in institutions, as a result of poor infrastructure and a shortage of human resources. In addition to this, only 17% of Human Immunodeficiency Virus (HIV) testing during pregnancy are taking place. Tracking and review of maternal deaths has to be prioritized. Ante natal care is also compromised. The stipulated four ANC visits are not followed in many of the districts. In PNC, even after institutional deliveries, only 50% of newborns are weighed, and staff is not trained to detect early warning signs for conditions such as post-partum haemorrhages etc.
The survey was administered as a functionality assessment, to understand the knowledge within the community regarding the VHSNC and its activities, as well as the retention of the information the VHSNC aims to dispense among the population. The survey covered 30 VHSNCs spread across 30 villages of five blocks in Jodhpur.Among the 30 potential VHSNC members surveyed, only 23 respondents were aware of the existence of such an institution. Fifteen responded they had received some orientation/training, however the nature and standards met in these orientations is unknown. About nine respondents who got training said they are aware about the functioning of VHSNC. Regular meetings of the VHSNC were reported by 11 respondents, although only two stated documentation taking place during the sessions.
Financial functionality was assessed by enquiring about the existence of a joint account and getting information on expenditure for the 2011-12 financial years. About 16 respondents reported that their VHSNCs have a joint account, however among these, only six spent INR 10,000 which is the annual allocation to VHSNC in the last financial year. Responses from the community revealed that awareness about VHSNC and its functions within the community is quite low.
Twenty focus Group discussions were conducted in Abu Road tehsil(sub district), Sirohi District of Rajasthan, with the aim of gauging barriers to accessing health care, according to the populations that are affected by these and to understand the involvement of PRI members in health issues. Each groups constitutes of 30 members with a marginally higher proportion of females in each group.
Physical access to existing health services were highlighted. Women, in particular, emphasized the distance to the clinic as a hindrance to their accessing healthcare Due to this lack of connectivity, the 108 ambulance service provided by the government, cannot be availed of by the villagers.
The functionality on the part of the health system was also discussed, in regard to its role in accessing health care. It was stated that health centers should ensure the regular presence of doctors, for the benefit of women’s and children’s health. Poor knowledge dispensing by PRIs and ANMs, regarding health services, was also listed as a cause for low awareness among the populations.
In addition to improving existing health system functionality, the respondents stated that the introduction of some new services would be beneficial for the population. Request for blood bank, diagnostic labs. The non-availability of drugs in the health centre was discussed and it was suggested to have uninterrupted drug supply covering the common conditions should be made available. Deldar Panchayats initiative to introduce diagnostic lab in PHCs was mentioned as success story.
Fixing responsibilities or lack of clarity in terms of accountability was mentioned at several discussions, with respondents requiring that a list of the names of the members of the civil justice society at the panchayat level, be pasted outside PHCs, for the access of the entire population. With this, villagers would have the option of addressing these members directly, regarding the healthcare provisions that they are entitled to.
The study reiterates the inter-connectedness of the numerous medical and non-medical determinants in the area chosen for study. However, similar circumstances have been revealed to exist in other parts of the country by other researchers. Managing the multiplicity of factors and their numerous interactions will have to be streamlined by an appropriate program that combines the local context with the national scene.
Access to healthcare is not merely a function of availability of hospitals or even adequate staff strengths. These factors, while important, might still prove by and of themselves insufficient to significantly improve quality of healthcare in community. Evidence is fast accumulating from both developed and developing countries that health systems are most effective when they are sensitive to the felt needs of the population, including cultural norms and historical experience.7 This points towards the need for developing organizational forms that enable the right mix of ‘hard’ capabilities in delivering services with ‘soft’ skills in managing people – both staff and beneficiaries. The flow of control and information – which generally happens in opposite directions in an organizational hierarchy – must be maintained at an appropriate balance that neither is hindered by the other.
Decision-making power in any organisation is distributed among various levels. Especially when publicly owned, organisational structure tends to be that of a bureaucracy. As a principle of rational organisation, bureaucracies are designed for stability and effective control of complex systems. However, it could lead to over-centralization of authority with resultant loss of flexibility and responsiveness.
On the other hand, an extreme degree of decentralization is likely to result in wide variations between units making inter-operability difficult, adversely affecting institutional integrity and ultimately resulting in systemic breakdown. Without reference to an impersonal set of regulations to ensure uniformity, the standards of good governance are unlikely to be met over a period of time.
The appropriate structure of authority should thus be one that is able to provide the right degree of “top-down” expert knowledge and management, while at same time is not so far removed from the intended beneficiaries as to be unable to understand and respond to local requirements and sensitivities. Only a health system with “bottom-up” capacity to respond to population needs will be able to build resilience into health systems in the face of political unrest, economic crises, and natural disasters etc.
Keeping this in mind, we shall now briefly look at some of the distinct models of low-cost health system management adopted in different parts of the developing world and assess the suitability of each to the Indian situation. Each of these represent a success story in its own right, yet even as there are broad similarities between them there are also significant differences that make for a compelling comparative study.
In Bangladesh, a high-level political commitment to health dates back to the period before independence.2 This commitment has endured despite major political changes. The country now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south Asia, despite spending less on health care than several neighbouring countries. This process was facilitated by institutional continuity of civil servants and by partnerships between government and the non-governmental sector.8 There was heavy emphasis on a community-based population policy, investment in indigenous expertise in generic drugs manufacture as well as small-scale integrated primary care, human resources innovations that created cadres of health assistants and family-welfare assistants, all complimented by progressive policies pursued outside the health sector, including education and female empowerment.
In Ethiopia, the transitional government that came to power in 1991 inherited one of the poorest and least developed countries in Africa that, on top of all of its other problems, was just emerging from a bitter civil war.9 Twenty years later, the transformation of Ethiopia is remarkable, attributable in large part to an innovative approach to create a health workforce.10 Under the health extension programme, which was managed by district governments, women with at least 10 years of education were recruited from local communities and given basic training in how to tackle common diseases. These initiatives have been backed up by regional and national investment in primary care infrastructure, essential drugs supplies, and management information. Successive sustainable development and poverty reduction programmes saw health as a contributor to and beneficiary of development. Investment was made in institutional strengthening, such as for example, the pharmaceutical fund and supply agency that is credited with reducing the time taken to procure drugs.11 The role of visionary political leadership and external aid have also to be noted.
Kyrgyzstan is a mountainous region, with less than 10% of land suitable for agriculture. Internal communications are often difficult. Yet the country stands alone in central Asia as an example of successful health system reform. It has implemented a functioning health insurance system and has succeeded in shifting care out of hospitals and into a strengthened system of primary care, achieving nearly universal access. The first of a series of health reform programmes was launched in 1996; it was promoted as an example of how government reforms would benefit the people, thus linking its success to that of the government.12 A mandatory single payer health insurance fund was created, expanding as resources have allowed and now covering more than 80% of the population. This fund is complemented by a state-guaranteed benefits package for vulnerable populations; an additional drugs package subsidises essential medicines. A prospective case-based system for inpatient care and a capitation-based scheme for primary care have been implemented.13 Endemic informal payments have been reduced substantially. Almost all primary care doctors were retrained as family practitioners, supported by nurses and midwives and better-trained mid-level health workers, including Soviet-era feldshers (auxiliaries). Coverage gaps in isolated mountain areas were addressed by village health committees, with volunteers contributing to basic preventive and treatment interventions. Kyrgysthan remains a foremost example of how political will and leadership can transform a grave challenge – in this case a health system inherited from the Soviet era that faced imminent collapse – to an opportunity for the better. A functioning legislative system guaranteeing the independence of civil servants ensured the continuity of programmes (seen in the successive Manas health programmes) and staff at times of political change.14
Thailand is another country that has made impressive health gains in the past 25 years. After the Millennium Development Goals (MDGs) were met, Thailand adopted country-specific targets known as MDG Plus, which underpin its development policy.15 The achievements seen in Thailand are associated with progressive expansion of health-care coverage. In 2001, the government unified a series of existing but fragmented systems to achieve near-universal health coverage even though, at the time, the region was affected by the Asian financial crisis. Health-care utilisation increased and catastrophic expenditure and out-of-pocket payments fell substantially. The country saw an exodus of doctors during the Vietnam War, with many Thai graduates moving to the USA. The government introduced a bonding system, requiring newly qualified doctors to spend three years in government health facilities, mostly in rural areas. This scheme was later extended to other health professionals, notably nurses who were not being trained in adequate numbers. A two year technical nurse diploma course was introduced in 1982 in place of four year training. After four years of mandatory rural health service, technical nurses could undertake an additional two years of training to obtain a bachelor’s degree and professional qualification. These policies resulted in substantially augmented numbers of doctors and nurses serving in rural district health services.16 The high priority given to health by successive governments, reflected not only in statements by politicians but also in successive national plans. Thailand has had several charismatic health ministers, again under both military and civilian governments, many with a high level of technical expertise. Other influential leaders in academia, health-care delivery, and civil society too have played a part. The Thai monarchy has provided a point of stability during political changes and has also had an active role in promotion of health. Institutional capacity building was important in Thailand’s success. Many senior staff have been trained overseas and have benefited from stable employment in the public sector, ensuring continuity and institutional memory. Non-governmental organisations and professional bodies have also played a positive part. Finally, the ability to translate health policies into practice has been facilitated by strong managerial capacity in provinces and districts, coupled with extensive piloting and evaluation to ensure that policies take full account of the Thai context.
We now come to the Indian state of Tamil Nadu, which, has also achieved notable success. Despite spending only about 1% of its gross domestic product on health, this region has made great progress in improving population health.17 A characteristic of Tamil Nadu’s success is the high health-care coverage. Four health system-related factors underpin these achievements. Firstly, it implemented in large scale a multipurpose worker scheme in which women with at least 10 years of schooling were trained for 18 months to become village health nurses. Existing maternity assistants were retrained and new training facilities were built. Tamil Nadu was also one of the first states to build a vast network of PHCs and sub-centers giving one of the highest levels of coverage of any Indian state. Innovative approaches to funding and construction were used in Tamil Nadu, including volunteer labour from communities. Health centres began to function 24 hours in the mid-1990s and is now the norm, with performance monitored monthly. By the early 1990s, Tamil Nadu had achieved the highest immunisation coverage in India, with the narrowest gap between the richest and poorest quintiles and between rural and urban areas.18 Integration of immunisation within primary care had assisted this achievement. Finally, a reliable supply of essential drugs was established in the form of the autonomous Tamil Nadu Medical Services Corporation (TNMSC).19 Outside the health sector, important successes in Tamil Nadu have included female empowerment and investment in infrastructure, in particular electricity and clean water. The achievements seen in Tamil Nadu were made possible in several ways. First, a strong commitment to health was made by successive state governments, which persisted despite frequent changes to the party in power. Second, successive health secretaries drove forward innovation and were supported by civil servants with both technical expertise and power to implement wide-ranging reforms. Sometimes, quasi-governmental organizations had to be created, such as the TNMSC, which could circumvent tardy bureaucratic processes. Third, investment in managers trained in technical public health skills and management at district level was sustained over many years, a unique cadre in India. A system of career progression has allowed Tamil Nadu to attract and retain high-calibre staff . Fourth, the partnership between government and NGOs was important, especially in the management of Acquired Immuno Deficiency Syndrome (AIDS) and TB.
The current study highlights the multiplicity of factors that could raise barriers to healthcare access. These range from such obvious ones as lack of infrastructure or large distances, to such elements as information barriers, cultural outlooks etc that tend to be overlooked in many cases.
There are serious deficiencies in infrastructure, staffing and funding that need to be addressed on a sustained basis. However, better management of available resources and generation of good quality information regarding unmet needs of the population are prerequisites to management of any health system, more so in a developing country.
The role of political stability and visionary leadership aided by a committed bureaucracy have been central to the changes outlined in each case discussed herein. Of crucial importance is a willingness to look at a range of pragmatic solutions, such as flexible models of public–private collaboration that take account of local context. Political commitment, good governance and effective bureaucracies that preserve institutional memory have for long been identified as key aspects of good governance that can explain the difference in outcomes between countries with a similar or comparable resourse base.2
Various Stakeholders have asserted that unresponsiveness of the health system has a major role to play in how populations access health care. In many areas where the community finds government health services wanting, they have to seek health care at private institutions, due to inadequacy of services and unacceptable behaviour of health staff. As this causes out of pocket expenditure, they are less likely to seek treatment. On a positive note, it was stated that due to good infrastructure in the Udaipur district, a rise has been seen in institutional deliveries.
Efforts should be to build on complementary capacities in every sector, to expand services responding to diverse needs. Whereas these collaborations should happen at different levels, however in the Indian context the district holds a distinct advantage in terms of administrative structure, operative convenience and proximity to beneficiaries.
Conflict of Interest: None declared
- As of the 6th CRM, 15 states were covered: Bihar, Chhattisgarh, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, Uttar Pradesh [High Focus category]; Assam, Manipur, Tripura [North Eastern category]; Delhi, Kerala, Punjab, Tamil Nadu and West Bengal [Non High Focus category]. Of these states, Rajasthan, Odisha, Chhattisgarh and Uttar Pradesh are those that have been visited in the course of all six CRMs.
- ii. The National Rural Health Mission was launched in 2005 by the Ministry of Health and Family Welfare (MoHFW), Government of India, to “carry out necessary architectural correction in the basic health care delivery system.” The NRHM [2005-2012] was envisaged to provide effective healthcare to rural populations throughout the country with a special focus on selected states. Its aim was to increase public expenditure on health, reduce regional imbalance in the health infrastructure, pool resources, integrate organizational structures, optimize health manpower, decentralize health management, encourage community participation and ownership of assets and optimize the functionality of health facilities to provide quality health care to every block in the country. In these motivations, the Mission places a special focus on the vulnerable sections of the society, the poor, women and children, and rural populations.
- The population of Rajasthan, as of 2013 falls at 71,041,283, with a growth rate of 21.44% over the past decade. According to the census of 2011, the urban to rural population ratio of the state is 75% to 25%. Administratively, the state consists of 33 districts, divided into 237 blocks, made of 44762 villages. It has a network of 34 district hospitals, 12 sub district hospitals, five satellite hospitals, 376 CHCs, 1517 PHCs and 11487 sub health centres.
- 108 Ambulance Project was launched in September 2008 by NRHM for free emergency services in India. When an emergency is reported to the toll-free telephone number 108, the call centre gathers the basic information including location and the nearest ambulance located using GPS is sent for assistance
- Lynch J, Smith GD, Harper S, Hillemeier M, Ross N, Kaplan GA, et al. Is income inequality a determinant of population health? Part 1. A systematic review. Milbank Q. 2004;82(1):5–99.
[Pubmed] | [Source]
- Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, et al. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet. 2013 Jun 15;381(9883):2118–33.
[Pubmed] | [Crossref]
- Government of India. Twelfth Five Year Plan (2012–2017) Social Sectors, Vol 3, pg. 5. Planning Commission. Government of India. SAGE Publications.
- M. Govinda Rao and Mita Choudhury. Health Care Financing Reforms in India. Working Paper No: 2012-100 March- 2012. National Institute of Public Finance and Policy
- Farag M, Nandakumar AK, Wallack S, Hodgkin D, Gaumer G, Erbil C. Health expenditures, health outcomes and the role of good governance. Int J Health Care Finance Econ. 2013 Mar;13(1):33–52.
[Pubmed] | [Crossref]
- Gupta M, Angeli F, van Schayck OCP, Bosma H. Effectiveness of a multiple-strategy community intervention to reduce maternal and child health inequalities in Haryana, North India: a mixed-methods study protocol. Glob Health Action. 2015;8:25987.
[Pubmed] | [Crossref]
- Saha S, Beach MC, Cooper LA. Patient Centeredness, Cultural Competence and Healthcare Quality. J Natl Med Assoc. 2008 Nov;100(11):1275–85.
- Gilson L, Sen PD, Mohammed S, Mujinja P. The potential of health sector non-governmental organizations: policy options. Health Policy Plan. 1994 Mar;9(1):14–24.
[Pubmed] | [Crossref]
- Parker, Ben. Ethiopia: breaking new ground. Oxfam, 2003.
- Levine, Ruth. Case studies in global health: millions saved. Jones & Bartlett Publishers, 2007
- Ali EE, Gilani A-H, Gedif T. Pharmaceutical Pricing in Ethiopia. In: Babar Z-U-D, editor. Pharmaceutical Prices in the 21st Century. Springer International Publishing; 2015 [cited 2016 May 3]. p. 79–91.
- Berman, Peter, and Thomas Bossert. “A decade of health sector reform in developing countries: what have we learned.” Washington, UNAID, 2000.
- Jakab, Melitta, and Elina Manjieva. The Kyrgyz Republic: Good Practices in Expanding Health Care Coverage, 1991–2006. Good Practices in Health Financing 2008: 269
- Ibraimova Ainura, Baktygul Akkazieva, Aibek Ibraimov, E. Manzhieva, and B. Rechel. Kyrgyzstan: Health system review. Health Systems in Transition 13, no. 3 (2010): xiii-xv.
- Patcharanarumol, Walaiporn, Viroj Tangcharoensathien, Supon Limwattananon, Warisa Panichkriangkrai, Kumaree Pachanee et al. Why and how did Thailand achieve good health at low cost. Good health at low cost’ 25 years on What makes a successful health system (2011): 193-223.
- Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006 May 27;4:12.
[Pubmed] | [Crossref]
- Gupta, Monika Das, B. R. Desikachari, Rajendra Shukla, T. V. Somanathan, P. Padmanaban et al. How Might India’s Public Health Systems Be Strengthened? Lessons from Tamil Nadu. Economic and Political Weekly 45, no. 10 (2010): 6.
- Muraleedharan, V. R., Umakant Dash, and Lucy Gilson. Tamil Nadu 1980s–2005: a success story in India. ‘Good health at low cost’ 25 years on (2009): 159.
- Lalitha, N. Government Intervention and Prices of Medicines: Lessons from Tamil Nadu. No. 175. Gujarat Institute of Development Research, 2007.