|Year : 2020 | Volume
| Issue : 4 | Page : 417-420
Addressing health inequity through strategic planning and management
Sumant Swain1, Divya Aggarwal1, Sanjiv Kumar2
1 Assistant Professor, International Institute of Health Management Research, New Delhi, India
2 Director, International Institute of Health Management Research, New Delhi, India
|Date of Submission||16-Jul-2019|
|Date of Decision||11-Sep-2019|
|Date of Acceptance||05-Sep-2020|
|Date of Web Publication||11-Dec-2020|
International Institute of Health Management Research, Plot No-3, HAF Pocket, Sector-18(A), Phase-II, Dwarka, New Delhi - 110 075
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Substantial progress has been made to improve health in India in terms of availability, accessibility, cost-effectiveness, and quality. However, there are major health inequalities between and within the states. Strategic planning of health programs is required to address inequities in health. Need of the hour is to address this using a simplified strategic approach; who is left out, why are they left out, what causes are responsible for it and what are the determinants of inequality. The basic steps of strategic management, including strategic assessment, objectives, strategy formulation, and implementation, can be used to address the health equity. This article cites the examples of Serbia immunization programme, Government of India programme on Mission Indradhanush, and Thailand's universal health coverage to get better understanding to use strategic management to address health inequity. This approach is crucial in achieving sustainable development goals.
Keywords: Health equity, health inequity, strategic management, strategic management framework
|How to cite this article:|
Swain S, Aggarwal D, Kumar S. Addressing health inequity through strategic planning and management. Indian J Public Health 2020;64:417-20
|How to cite this URL:|
Swain S, Aggarwal D, Kumar S. Addressing health inequity through strategic planning and management. Indian J Public Health [serial online] 2020 [cited 2021 Sep 26];64:417-20. Available from: https://www.ijph.in/text.asp?2020/64/4/417/303096
| Introduction|| |
Globally substantial progress has been made to improve health. However, there are major health inequities between and within the countries. It is more pronounced in urban than rural area. Strategic management of health programs is required to address inequities in health. The Black Report (United Kingdom) in 1980 brought a more focused approach to inequity in health by identifying the specific factors such as social class, gender, race/ethnicity, and social and economic determinants. The United Kingdom government had established a commission on “Independent Inquiry into Inequalities in Health” to suggest way forward in 1997. In 1998, the WHO's European Regional Office adopted Health for All policy (Health 21) which specifies that by 2020 the health gap between countries and between socioeconomic groups to be reduced by at least one fourth in all member states. The Alma-Ata summit advocated the achievement of greater health equity and the reduction of health disparities as national goals. India adopted its first health policy in 1983 to achieve health for all by 2000.
In India, the National Family Health Surveys reveal large disparities in service coverage between different parts of country. To address this, Government of India has launched National Health Mission in 2005, National Health Policy 2017 and Health and Wellness Centers (February 2018) and Pradhan Mantri Jan Arogya Yojana (September 2018) under Ayushman Bharat programme.
| Health Equity|| |
Health equity implies everyone has equal opportunity to avail health services irrespective of education, economic status, gender, ethnicity, and geographical differences. Pursuing health equity indicates striving for the highest possible standard of health for all people with special attention to those at greatest risk of poor health, based on social conditions. To achieve health equity requires action on the social determinants of health. Social determinants of health include income/wealth, food, nutrition, education and life-long learning, water and sanitation, decent work, fair employment, health care, and environment. Health equity is achieved when every person has the opportunity to achieve their full potential for health. In operational terms, pursuing equity in health means eliminating health disparities that are systematically associated with underlying social disadvantage or marginalization. No one should be denied the resources needed to be healthy, including not only medical care but also health-promoting living and working conditions.
| Determinants of Health Equity|| |
An equity focused health policy is a necessity in developing countries due to the public good characteristics of health care and risk of information asymmetry. The Indian health scenario exhibits a co-existence of improving health indicators and widening socio-economic and health disparities. Although socially excluded and minority groups are particularly vulnerable to ill health, differences in rates of illness affect everyone: Health status diminishes continually along what is called the “social gradient in health.”
The millennium development goals (MDGs) helped to lift more than one billion people out of extreme poverty, made inroads against hunger and enabled more girls than ever before to attend school. However, inequalities persist and the progress has been uneven. The world's poor remain overwhelmingly concentrated in the some parts of the world. Disparities between the rural and urban areas remain pronounced. The Sustainable Development Goals (SDGs) build on the success of the MDGs and can be grouped into Environment, Poverty, and Inequality and Peace and offer an excellent opportunity to address social determinants of health inequity. All of them contribute to health directly or indirectly [Figure 1].
|Figure 1: Sustainable development goals and their contribution to social determinants of health and health goal.|
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| Whole of Population Approach to Health in Reducing Inequity|| |
In order to address inequity, whole of population approach should be adopted [Figure 2]. The whole population can be divided into four groups: (a) healthy population, (b) population with risk factors, (c) population with symptoms, and (d) population with disease. To address inequity in a sustainable manner each of these groups needs to be targeted with specific interventions. This approach encompasses primordial prevention for healthy population and curative and rehabilitative care of the segment of population with disease.
|Figure 2: Whole of population approach for equitable health (adapted from).|
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| Role of Strategic Management in Addressing Health Equities|| |
Planning is the most important component of every health programme. It appraises the overall health needs of a geographic area or population and determines how these needs can be met in the most effective manner through the allocation of existing and anticipated future resources. However, the strategic management is about envisioning and realizing the future. In health programs, it is concentrates toward achieving the vision, mission, goals, and objectives of a program on the long-term basis and study the internal and external environment and execute accordingly. Strategic management appraises the overall health needs of a population and how to meet these needs in an effective manner. Thus, it is future oriented, whereas strategy is action oriented. Strategic management is essential for successful implementation of health programme addressing inequities. It implies a set of decisions taken in relation to the formulation and execution of strategies to achieve programme goals. It is an action orientated process to improve the health care outcome or strategic results. Strategic management addresses four core areas, i.e., where are we, where we want to reach, how we reach there, and what actions we need to take to reach there. The difference between routine planning and strategic planning is the rigor with which specific questions are addressed to ensure achievement of the programme objectives. Strategic planning has been done in some of the programs such as HIV/AIDS, malaria, and tuberculosis.
Given below are the three examples to elucidate the strategic planning and management approach to address inequity in health:
Serbia Reaching unimmunized Roma children
Serbia had achieved immunization coverage of 95%. This meant that approximately 40,000 (5%) children were unvaccinated. The government with UNICEF support conducted a study to find out who they were and why these children were left out. It revealed that most of these children belonged to nomadic Roma community and the main reason was that they rarely visited the health centers for services. Health department consulted community leaders and adopted the strategy to provide outreach immunization to where they were, and monitored the progress on daily basis. As a result, the government achieved more than 80% immunization among Roma children.
India Mission Indradhanush to reach unimmunized children
India was concerned about slow progress of full immunization coverage from 61% in 2009 to 65% in 2013. The government launched Mission Indradhanush in 2014 to accelerate progress to reach the unreached populations by 2020. The strategy included microplanning to target unvaccinated with accountability and local ownership. It included political support and sustainable financing. The program between April 2015 and July 2017 contributed to an increase of 6.7% in full immunization coverage (7.9% in rural areas and 3.1% in urban areas) after the first two phases. In October 2017, the government strengthened it by launching Intensified Mission Indradhanush to reach 90% coverage in identified districts and urban areas with persistently low coverage from December 2019 to March 2020. To identify and reach the unreached the government mobilized several ministries, including the Ministry of Women and Child Development, Panchayati Raj, Ministry of Urban Development, Ministry of Youth Affairs and others came together to make the mission a success.
Universal health coverage in Thailand
In Thailand, evidence revealed an improving trend in health equity in terms of both access and financial protection in UHC (Universal Health Coverage). However, 30% of the population was left out despite Medical Welfare Scheme of the poor, the elderly and children under 12 years, social health insurance scheme for private sector employees, Civil Servant Medical Benefit Scheme for government employees, retirees and dependents and publicly subsidized health insurance for the informal sector. To cover those left out, the Government targeted those left out in a scheme meant only for them called Universal Coverage Scheme. Two household surveys (Socio-Economic Survey and the Health and Welfare Survey) showed that catastrophic incidence dropped from 5.4% in 2000 to 3.3% in 2002, 2.8% in 2004, and 2.0% in 2006.
| Way Forward|| |
The current health planning in India referred to as programme implementation plan under NHM is target oriented and does not include strategic approach specifically targeted to reach the unreached. This leaves a proportion of population not reached for various health interventions enhancing inequity. A shift to strategic approach to planning will help in identification of those who are left out, reasons thereof, piloting to reach them and continuously monitoring and revising the strategy to achieve universal coverage and achieve health equity. Since inequity in health results from social determinants, health professionals need to be aware of it and use opportunities such as SDGs to address inequity. Within health sector, the programme managers, while planning, need to regularly ask four questions; (1) Who is left out? (2) Why they are left out? (3) What need to be done and pilot suggested approach? (4) Are we reaching the unreached with a new approach by using disaggregated data to monitor the coverage among targeting unreached population groups. This simple strategic management framework approach is important to achieve equity in health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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