WHO-AHPSR Case Study of the IHS.

The Alliance for Health Policy and Systems Research (APHSR) is an international collaboration based within the World Health Organisation (WHO). In 2009 to 2010, the WHO-AHPSR undertook a study of Health Policy Analysis Institutes (HPAI) in low- and middle-income countries. Sara Bennett of the WHO-AHPSR was the lead author of this study. A total of 78 HPAIs consisting of 38 institutions in Asia and 21 in Africa could be listed at the time. Six out of the 78 institutions were selected for detailed case study. The Institute of Health Systems (IHS) Hyderabad, happened to be one of these six Institutions taken up by the WHO-AHPSR for case study. Each of the case studies was conducted by a researcher from the concerned country or region. The AHPSR final report summarises the landscape of on Health Policy Analysis Institutes in Asia and Africa at the time (Bennett et al, 2010). Experiences of HPAIs influencing policy changes has been reported by Bennett and others (2012).

Download: Bennett et al 2010; Health Policy Analysis Institutes: Landscaping and Learning from Experience. Final Report.

Link to: Bennett et al 2012; Influencing policy change: the experience of health think tanks in low- and middle-income countries, HPP 27(3).

Dr. Amar Jesani was commissioned for the IHS case study. Dr. Jesani examined institutional documents, interviewed key informants, directly observed work at the IHS and interacted with staff. Key informants included clients, Board and Executive Council members, current and former Director and staff members. Final Report of the IHS case study by is available for download (Jesani, 2010).

Download: Jesani, 2010; Health Policy Analysis Institute - India Case Study: The Institute of Health System (IHS).

Author's Conclusion:
(Extract from the IHS Case Study, 2010)

The IHS has in last 20 years gradually grown and found a niche for itself. Unlike many classical NGOs of late 1960s and of 1970s – which emerged from a strong critique of the government and the bureaucratization of services – the IHS is an NGO that emerged from the needs of the government services and with the direct private initiative and involvement of the bureaucrats. Although over years it has remained low funded and have had very few senior health researchers at any point of time, it could still play some important role in the state and national level health policy arena. While the IHS has evidently maintained fair amount of independence in the research carried out by it, there are skeptics who feel that it needs to do more in order to set its own agenda and lead the state in having appropriate policies. Indeed, as the IHS develops into a more stable and bigger institution, it may be able to do so if it is able to put together a critical mass of competent faculty having strong independent pro-people perspective.

In whatever direction it goes, it still have to find some solution for its long term sustainability. In the present situation in the country when the NGOs are not able to mobilize core institutional funds, whatever bold initiative it takes for this will be having its own risk. But there is no way it can avoid such risk taking, it can only do better planning to avoid any harm to the institution in case some of its plans do not succeed. So in that sense, its efforts to set up its own campus and begin public health training courses are for improving its chances for long term sustainability.

Two decades of development – a long view:
(Extracts from the IHS Case Study, 2010)

In terms of functional development, the last two decades of the IHS could be viewed in five phases: The first phase of three to four years (1991 to 1993-4) was primarily of voluntarism and in the process, create space for an organization. The second phase (1994-5 to 1997-8) was that of struggle to give a formal shape to institution. The third phase (1998-9 to 2002-3) was that of rapid expansion to operationalise the vision of establishing it as public health training institution. The fourth phase (2003-4 to 2008-9) was that of set-back to the expansion plan, the slump and the revival of the institution. The fifth phase (2009-10 onwards) has begun with a plan to put in place a campus with infra-structure, the establishment of public health training and of course more pragmatic collaborations to make the plan work.

First phase (1991 to 1993-4):

In the first phase (1991 to 1993-4) much of the research work was supervised voluntarily by Dr. Mahapatra, except in the last one year when the IHS had a full-time director. Ten working papers were published by the IHS in this period, seven of them with Dr. Mahapatra as first author (some of them with co-authors), one with Dr. Ramana, the full-time director as the first author and the remaining two being the proceedings of the meetings organized by the institute. Three papers were also published in journals – two in Indian journals and one in international journal.

In this phase the main areas of interests of the IHS in the public health research started taking shape. Clearly the topics examined were the health service financing – the state and the voluntary sectors in particular, the research in disease condition like asthma, research in the health service system of the state, and above all the first foray to explore the field of herbal and traditional medicine and medicinal plants by organizing a seminar on the subject.

Second phase (1994-5 to 1997-98):

In the second phase (1994-5 to 1997-8) was mainly supervised by a full-time director. The IHS did not publish any working paper in 1995. In 1996 and 1997 (perhaps up to first half of 1998), eight working papers were published. Four of these papers have the then director Dr. Alex George as first author (some with co-authors) and the remaining four are institutional publications being technical note, database and baseline and exploratory surveys.

In this period, more work on the health system was carried out, with studies on hospital accreditation, hospital autonomy in the APVVP, patient satisfaction surveys, preparation of the health institutions data base of the state, quality of reproductive health services and health status surveys. In this phase the IHS also did work in Mauritius health systems.

Third phase (1998-9 to 2003):

The third phase of the IHS (1998-9 to 2003) was evidently the phase of rapid expansion. This was the time when Dr. Mahapatra joined the institute on deputation from the government as the direct head of the institution, acquired a big office space, instituted training programs including a post-graduate course in health administration and recruited several faculty members. In this period 34 working papers came out. Of the 34, Dr. Mahapatra is first author for 27 (some of them co-authored with others), in one he is third author, one is document on the standards for reproductive health brought out by the institution and the remaining five papers are authored by the consultants and the faculty.

All five books published by the IHS were also brought out in this period. Dr. Mahapatra is first author of four of them, while the fifth is the report of meeting organized by the IHS. In addition, from 1998, the IHS also started publishing reports of the projects done by it. 23 reports of the projects or studies were also published in this period. In 11 of these reports, Dr. Mahapatra is the first author. Seven of these reports are in the institute’s name without any author listed, while the remaining five are authored by the faculty and consultants. The publications in the journal and in books as contribution of chapters also increased – eight such papers were published in this period.

It must be kept in mind that the increase in the number of publications by the IHS and in the journals, some of them were based on the research conducted in the earlier phase, while some were based on the work done by Dr. Mahapatra while he was studying in the USA. Nevertheless, as compared to the first two phases the research output was extra-ordinarily high in this period.

The health policy and system research contribution in the third phase:

From the number of publications and more importantly, the number of initiatives taken by the IHS in this period, this phase was the golden period of the IHS. From the information gathered by us from the BoG members and the staff, it is clear that the IHS made its presence felt at the state, national and international level in this period. A brief account of some significant work carried out by the IHS in this period is given below.

International level:

The IHS made a significant contribution in the area of burden of disease methodology. While the IHS was already involved in conceptualizing this work before this phase began, important part of the work was carried out and published in this period. The IHS undertook the task of community based surveys to estimate the health state valuation or disability weight that is essential for measuring the burden of disease in a country. For this work the IHS collaborated with the Administrative Staff College of India and conducted one of the earliest burden of diseases studies.

The second work of importance in this period was development of sampling design for the health system responsiveness survey of the WHO. The IHS developed the sampling design for India and Andhra Pradesh, and the same was shared with the WHO, which used it or recommending sampling design for other countries.

National level and contribution to other states:

The IHS worked on the cause of death statistics of the country and published two papers in the journal. This work attracted the attention of the Registrar General of India, and triggered of more studies on the SRS (Sample Registration System) – based cause of death program and the statistics. Another area that the IHS impacted at national level was through its work at international level on the burden of diseases. The Indian Council of Medical Research (ICMR) sent its scientists to the IHS for training in the burden of diseases methodology. Such recognition of the IHS by the ICMR was very important achievement of the institute.

At the request of the Ministry of Health and Family Welfare, the IHS designed a family health insurance policy in 2002. This policy generated lots of debate within the ministry, including a workshop where it was discussed, but the government did not act on it. Presently the government of India and different state governments have come out with several insurance policies but none is in line with the one recommended by the IHS. According to Dr. Mahapatra:

Sad thing for IHS is that the government of India has not yet accepted the policy or the plan that IHS recommended. Rather government of India and the state governments are adopting health insurance policies which are to the detriment of the long-term health of the health sector … long-term financial health of the health sector. But IHS has made a significant contribution in the fact that this policy that is being pursued today by the government of India is not due to lack of any access to an appropriate proposal. It is despite an appropriate proposal …

In 2003 the IHS organized a meeting and also prepared a sampling design for the prevalence study of the HIV in the country for the National AIDS Control Organisation (NACO). The development of methodology for such a survey was done by a consortium and that methodology was later used by the third National Family Health Survey to estimate the HIV prevalence.

Another area of interest of the IHS has been the health informatics. It commenced its work in this area in this period and set up training programs. The IHS took membership of the HL7 organisation hosted by the Duke University, USA, and started providing training in the HL7 to software developers in the country for modernization of the hospitals and health care institutions. About 100 persons were trained in this period.

Lastly, the IHS also made forays in other states – Maharashtra, Madhya Pradesh, Orissa and Gujarat making some contribution in the health system development work there.

In Andhra Pradesh: The IHS did work on several projects for the state government. One area was work on specific diseases. Two manuals, one for malaria and another gastro-enteritis control programs were commissioned by the state government. Two other diseases on which research was done were Tuberculosis and HIV.

The IHS also took ahead its work on the health service system. Several surveys on patient satisfaction in the state hospitals were carried out, contribution made in the management of hospitals, including in the task of computerization of the Management Information System. At the same time attention was given to the private sector in the state, particularly on the issue of accreditation of private hospitals. Similarly obstetric care at a district level was examined and research on reproductive health care was taken up. This component also included training of the medical officers and auxiliary nurse midwives from primary health centre. In this period the IHS also worked on the essential health research issues by doing research on the priority setting in health sector.

As mentioned earlier, the field work for the national and international level contributions in burden of diseases, causes of death statistics and health responsiveness projects was conducted in Andhra Pradesh.

Fourth phase (2003-4 to 2008-9):

The fourth phase (2003-4 to 2008-9) began disastrously for the IHS. The relatively big expansion of the institute in the previous phase could not be sustained due to setbacks. The training for PG course in health administration nose-dived and the institute was forced to close it because it could not obtain recognition for the course from the university. With that went the students. Dr. Mahapatra’s tenure for the deputation got over and he went back to his government job. The institute could not sustain financially and started defaulting in salary payment to the staff. So the faculty recruited for the expansion left one after another. The institute was burdened by the debt as it had to clear the salary bills of the staff that had left.

This is clearly reflected in its research outputs in the years 2004 and 05 – only three reports and two working papers were published. But the new director also began revival from the year 2004 onwards, and so the institute showed markedly improved research output from 2006. In 2006 it came out with eight research report and five working papers. This revival sustained thereafter, with eight research reports getting published in 2007 and 2008. However, the reduced faculty strength overburdened the director, resulting into no output in terms of working papers in those two years.

However, in this period some new area of work got added. First of all, it entered into collaboration with the Metropolitan Water Supply and Sewerage Board to establish water testing laboratory. This not only opened up a new area of work on the water supply and water borne diseases, but also created possibility of some income generation for the institution. In addition to the laboratory work, it also involves work of looking into the access to the safe drinking water in the under-served urban areas where the poor of the city live.

The work on the HIV was expanded with work to assess the social context of the HIV program and also the institutional assessment of the program. Another addition was examination of the epidemiology of the road traffic accidents in Hyderabad.

The work on the health care system and health financing areas was continued with, and it carried out some significant research in those areas. The IHS did assessment of critical gaps in rural health care system in Andhra Pradesh and was also involved in training health workers in the rural health care. It also prepared a district health plan for one district of the state.

In the health financing, it worked not only at the state level, but also did work on other states and at the national level. The most important of its work was on the national health accounts. It first undertook the preparation of the Andhra Pradesh state health account and then it was followed up with the preparation of a manual for the National Health Accounts for the WHO. It also prepared medium term expenditure framework for Andhra Pradesh, Madhya Pradesh and Orissa. Another notable work in this field was on the health financing and expenditure on the non-profit sector in Andhra Pradesh.

The course – “Advanced Studies in Public Health":

As mentioned earlier, this one year course, extended to two years, was commenced in the previous phase of the development of institution (2002-04). The establishment of this course much before all formalities for the recognition of the institute and the course by the University as well as the state government remains somewhat unclear to us. What is clear, though, is the fact that establishment of such course falls within the objectives and mission of the institution and objectively, there was and there is a great need for the capacity building and production of people trained in high quality people oriented public health. However, its timing and massive investment, so much so that it caused a financial crisis for the institution are difficult to issues to understand in the history of the IHS.

The former director of the IHS who had to bear the brunch of setback at that time explained that they knew very well that for three major reasons there was a likelihood of delay in getting the University and government recognition:

We had always expected that the process of affiliation would be difficult mainly for three reasons. Firstly, all other professional courses have central regulatory bodies which specify requirements for affiliation as well as syllabus. It is then easier for the University to determine whether an applicant meets the necessary requirements and accordingly take a decision to affiliate the institution. However, in case of public health there is no such body in India which meant that University would have to first develop guidelines and rules for the affiliation process. It is very unlikely that the University would take the initiative to do so in the absence of a sustained effort from IHS. Secondly, as in other States health and related subjects fall under the purview of the University of Health Sciences in Andhra Pradesh. The key decision makers in the University are of a medical background and who had so far only affiliated only medical and paramedical courses. We were apprehensive of how we could effectively communicate the need for a multidisciplinary course open to non-medical graduates also. Thirdly, the masters program we had developed was structured on a credit and semester system adopted by central universities in India as well as international universities. The program had other innovations with regard to selection of students and mode of examinations which were different from that adopted by the University.

Yet, the course was established and students recruited before getting the clearance from the appropriate authorities. As expected, the long delay did occur. The expectation that once such recognition was there, additional funds will be raised from various sources, including fees from students, could not materialize. The institute was forced to discontinue the course and wait for the next opportunity to launch it.

However, the key people involved in this endeavour, the then director and present President of the institution, and the former director who succeeded him, consistently defended the decision for the establishment of this course. While the GoB members we interviewed did mildly state that they went ahead of time or showed some hurry, none discussed in detail about that decision.

In our mind there is no doubt that establishment of this course was pre-mature, more so from a seasoned civil servant who understands the uncertainties of the speed with which various arms of the government and university function. However, the expressed ambiguity around the decision could be due to two reasons. First, the exercise carried out in establishment of the course – the development of course curriculum, methods of assessment, identification of the faculty, etc etc played an important role in obtaining the clearance from the university and the government later on. Besides, that also showed its seriousness for the government to allocate land to the institute. Second reason is the institutes decision to establish the course now with university and government recognition. When such process of establishing the Masters in Public Health course is on, the institute would like to look back at the earlier endeavour as something done in preparation of the one that is now actually getting established. The former director of the IHS thus said that:

I believe that in the long run investing our time and resources in the Advanced Studies in Public Health would bring significant returns to the Institute. As I mentioned earlier, if it was not for the program we would not have come to a stage where we have an affiliation to start the MPH program. In addition to fulfilling a major objective of the Institute, I believe that the MPH program is the key to the Institute’s sustainability. For the Institute to grow beyond the current scale of operations and be sustainable it will require significant support from the government and other donors. Such support will not be forthcoming unless we are able to demonstrate requirement of large scale funding as well as its potential outcomes. In the current scenario the MPH program is an excellent vehicle to seek such support. The affiliation for MPH played a significant role in getting the Institute 16 acres of land from the government. The availability of land plus MPH affiliation along with the Institute’s track record has tremendous potential to open further avenues of funding. If such funding materializes it is a key step to sustainability of the Institute as it broadens the financial base of the Institute. In addition to fees generated through academic programs, faculty put in place for academic programs will also be able to generate resources through sponsored research. I agree that it is an extremely challenging task for which the Institute must plan its strategy very carefully.

Fifth phase 2009 - :

The fifth phase of its work development has just begun from the later part of the 2009. While the new director took over at that time, the BoG also moved forward to operationalise its vision of having a campus of the institution. It negotiated and was awarded land at concessional price by the state government to build its own campus. It has also entered in to collaboration with the large non-profit organization, the LV Prasad Eye Hospital for starting the Masters of Public Health degree course. The University approval for beginning such a course has already been obtained.

Indeed, there is support from the government for establishing the MPH program by the IHS. The principal secretary stated the following:

In fact today you will be quite happy to know that we are amending the service rules in the state that if somebody wants to become district medical and health officer or additional district medical and health officer, he must or she must possess a master’s degree in public health.

He further added that as the medical officers are allowed to move in the hierarchy, there will also be a need to chart out the growth path for the other health workers so that they could, after receiving relevant training, also move up in the hierarchy. So their training could also be taken up by the organization like the IHS. He stated that:

So if I don’t give financial support to institutes like IHS, at least I insist my fellows to go for a training like this and provide opportunities in their jobs to go for a training program, I am sure they (i.e. IHS) will come with tailor made courses where individual can work for 1 month, go for 1 week training, go back again for 1 month work, go back again for 1 week training and gradually upgrade his own skills.

So clearly, the next step being planned by the IHS is in line with the need expressed by the state government.

Indeed, this new endeavour will bring new challenges for the IHS – both in terms of raising finances as well as recruiting competent faculty to run the public health education program and also to lead it research work.

Other Observations from the IHS Case Study:

1. The health policy research constitute a bulk of research work done by the IHS. It must be kept in mind that often the health policy research or contribution has emerged from the need expressed by the state or from the evidence gathered while doing operation research in the system – indeed, the very foundation of the IHS was laid for doing the operation system research for improving the management of health sector.
2. All through, two points came out very clearly: (a) that the IHS is not pursuing any partisan political or ideological agenda and (b) that it is committed to use scientific and democratic means for the health system improvement.
3. Several clients mentioned about the value system, honesty, integrity, and positive work culture of the IHS. The Institute has capacity to forge interdisciplinary team and commitment to work.
4. The current staff at the institute talked about several values of the IHS that they appreciated. They included, of course what the clients mentioned, the honesty and integrity, the discipline, system of work, etc. In addition, they mentioned the institutional commitment to high quality of work.
5. The individuals at the leadership level emphasized (in addition to high quality and integrity) the “commitment” as the most important value that the IHS cherished. The term commitment was imbued with a range of moral meanings. For instance, it was argued that “we should have some commitment so that we can really have satisfaction in helping people”. It is the “commitment” that makes people to forgo a government job or high paying private job offer; and join the IHS. The commitment could be to good scientific research; to high quality public health work, including research and training, to work with vulnerable strata of population, and so on.

References:

1. Bennett Sara; Corluka Adrijana; Doherty Jane; Aikins Ama de-Graft; Hussain AM Zakir; Jesani Amar; Kyabaggu Joseph; Namaganda Grace; Walaiporn Patacharanarumoi, and Tangcharoensathien. Health Policy Analysis Institutes: Landscaping and Learning from Experience. Final Report. Geneva: WHO Alliance for Health Policy and Systems Research; 2010 Jun 29.
2. Bennett Sara; Corluka Adrijana; Doherty Jane; Tangcharoensathien Viroj; Walaiporn Patacharanarumoi; Jesani Amar; Kyabaggu Joseph; Namaganda Grace; Hussain AM Zakir, and Aikins Ama de-Graft. Influencing policy change: the experience of health think tanks in low- and middle-income countries. Health Policy and Planning. 2012 May; 27(3):194-203 doi: 10.1093/heapol/czr035.
3. Jesani Amar. Health Policy Analysis Institute - India Case Study: The Institute of Health System (IHS). Hyderabad: The Institute of Health Systems; 2010; Report Series:RP53.

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