Swasthya Chaupal

Vikash R Keshri, January 2018

Bihar is one of largest state in eastern India. With population of more than 110 millions, health indicators of the state are very worrisome. During last decade very significant progress was made, leading to tremendous improvement in health indicators. Two factors probably played important role; first, the launch of national rural health mission and second, the progressive political leadership at local level. Still, much remains to be done for achieving long term health goals. State government, particularly the department of health has made incredible efforts to change the fate of state. This was also supported by complementary efforts of many international organizations. Driven by ethical logic and goal to achieve millennium development goals, the major focus of health improvement revolved around improving RMNCH (Reproductive, Maternal, New-born and Child Health) services. These efforts resulted in Reduction of Total Fertility Rate (TFR) from 4.2 to 3.2, Maternal Mortality Ratio (MMR) from 312 to 208 per 100,000 live births and Infant Mortality Rate (IMR) from 60 to 38 per 1000 live births. But many other health challenges remained stagnant. Recent data shows that after initial success, the rate of progress seems to be plateaued. The role of systems thinking for overall health systems improvement is needed now, more than ever.

But where is the evidence for evidence based policy making? One of the important bottlenecks for evidence based policy making is near paucity of research evidences to guide health systems evolution in the state. A PubMed search with Bihar in title fetch 429 results and with Bihar as general term fetch less than 2000 results. Most of these research actually focused on visceral leishmaniasis (or Kala-azar), considering the endemicity of disease in the state. Although, during last couple of years, an upsurge in number of research is noticed. These research mainly focused on topics related to RMNCH, leaving research intending to generate evidences for guiding health policy continued to be scarce. Based on this felt need the centre for health policy (CHP) was set up at the premier research institute based at capital, Patna. Asian Development Research Institute (ADRI), a research institute working on social and economic issues in the state for more than 25 years is a perfect host for a centre. CHP started functioning fully in August, 2017 with six members multidisciplinary team on board. With a mandate to propel the state’s policy towards achieving Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC), the CHP team started its ground work to carve out way for possible road map.

On December 19, 2017, almost six months after inception, the CHP organized first consultative workshop “Evidence Based Research on Health in Bihar”. The real watershed moment for this workshop was participation of all important policy makers and other stakeholders in the state. The objectives of the workshop were to discuss the initial research work and also to seek feedback on future research priorities. Originally scheduled for 12^th December in concurrence with global Universal Health Coverage-Day (UHC Day) celebration, the date was deferred due to unavoidable circumstances but the spirit to set tenor for evidence-based health policy making leading to stronger health system and finally UHC was never compromised. Top decision makers resonated the urgent need to have such think tank in the state. In total, seven research papers were discussed in three sessions during the day long meeting. Another unique feature of technical session was involvement of concerned policy makers as moderator. The appetite to understand, what is working and what is not was evidently palpable in the room.

The opening presentation provided details about the morbidity, health care seeking and health expenditure pattern in the state comparing the situation in 2015-16 with 2005-06. The findings indicated improved health care seeking by people, reduction in overall out of pocket expenditure (OOP) but rise in OOP for in-patient. The rise in OOP was even more for women and poorest of poor. Having health insurance led to more OOP and there were clear preferences for public facilities than private. Second presentation on Demography of Bihar, focused on profiling of the state to understand socio-economic variation among different districts and regions. IMR and TFR and their demographic distribution were also elaborated in detail. In addition, a comprehensive analysis of socio-demographic and economic characteristics of “SDG Generation” who will be part of workforce in 2030 were also presented. This profiling is targeted at policy direction to leverage the human resource capital in future. In most of resource constrained area, government’s role in health care is generally limited to that of a providers only. But in mixed health systems with dominant role of private sector, the role of government should be seen as steward of health systems. The third presentation focused on this aspect and aimed at motivating policy makers for introducing effective Regulation in Health Care. Based on experiences globally and from other Indian states, the role of regulation as a first important stepping stone towards UHC was highlighted.

In sessions following, the role of unmet need for family planning and its determinant and the predictors of Caesarian Section (Surgical birth) were deliberated. This was followed by presentation on role of Information and Communication Technology (ICT), highlighting the success stories of ICT in improving health care delivery. The last presentation of the day was on much needed and often neglected health issue i.e. “Mental Health”. The presentation focused on bringing human rights perspectives to mental health. All sessions were followed by exciting discussion with active involvement of all stakeholders.

With the crucial bond between the researchers and policy makers established, the issues like universal health coverage being discussed and deliberation on how health system design should shape for achieving sustainable development goals; the evidence-based policy making is arriving with a bang in an area where this is the need of the hour.