Globally, zoonotic diseases pose an enormous and growing public health challenge, and developing countries like India are at the epicentre of it. Although there is general recognition of this reality, governments around the world have struggled to organise appropriately to respond to it. The widely held view is that organising for One Health requires effective cross-sectoral collaboration, but the prerequisites to enable such collaboration appear almost unattainable. Perhaps an entirely different approach is needed, which is over and above effective collaborations between competing government ministries. The approach would have to recognise that while any organisational response will need to be able to address identified zoonotic diseases and respond effectively to them in times of crises, it would also be required to have the ability to shape the response to megatrends such as climate change, deforestation, and the underlying development models of the country. The paper analyses the success and failures associated with the way in which India, Bangladesh, Kenya, and Rwanda have organised for One Health. It also studies the underlying pathways through which zoonotic spillovers take place, and epidemics gather momentum. Based on these critical analyses, the paper concludes that attempts to build single overarching units to address these challenges have only been partially effective. Given the scale and complexity of the challenge, it recommends that, even at the risk of duplication and the very real possibility that unaddressed gaps will remain, an approach, which builds multiple sharply focused units, would have a greater chance of success.

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA’s overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Building good health systems is an important objective for policy makers in any country. Developing countries which are just starting out on their journeys need to do this by using their limited resources in the best way possible. The total health expenditure of a country exerts a significant influence on its health outcomes but, given the well-understood failures of price-based market-mechanisms, countries that spend the most money do not necessarily end-up building the best health systems. To help developing country policy makers gain a deeper insight into what factors matter, in this study the contribution of per-capita total, out-of-pocket, and pooled health expenditures, to the cross-country variation in Disability Adjusted Life Years lost per 100,000 population (DALY Rates), a summary measure of health outcomes, is estimated. The country-specific residuals from these analyses are then examined to understand the sources of the rest of the variation. The study finds that these measures are able to explain between 40 and 50% of the variation in theDALY Rateswith percentage increases in per-capita out-of-pocket and pooled expenditures being associated with improvements inDALY Ratesof about 0.06% and 0.095%, respectively. This suggests that while increases in per-capita total health expenditures do matter, moving them away from out-of-pocket to pooled has the potential to produce material improvements inDALY Rates, and that taken together these financial parameters are able to explain only about half the cross-country variation inDALY Rates. The analysis of the residuals from these regressions finds that while there may be a minimum level of per-capita total health expenditures (> $100) which needs to be crossed for a health system to perform (Bangladesh being a clear and sole exception), it is possible for countries to perform very well even at very low levels of these expenditures. Colombia, Thailand Honduras, Peru, Nicaragua, Jordan, Sri Lanka, and the Krygyz Republic, are examples of countries which have demonstrated this. It is also apparent from the analysis that while very high rates (> 75%) of pooling are essential to build truly high performing health systems (withDALYRates< 20, 000), a high level of pooling on its own is insufficient to deliver strong health outcomes, and also that even at lower levels of pooling it is possible for countries to out-perform their peers. This is apparent from the examples of Ecuador, Mexico, Honduras, Malaysia, Vietnam, Kyrgyz Republic, and Sri Lanka, which are all doing very well despite havingOOP%in the region of 40–60%. The analysis of residuals also suggests that while pooling (in any form) is definitely beneficial, countries with single payer systems are perhaps more effective than those with multiple payers perhaps because, despite their best efforts, they have insufficient market power over customers and providers to adequately manage the pulls and pressures of market forces. It can also be seen that countries and regions such as Honduras, Peru, Nicaragua, Jordan, Sri Lanka, Bangladesh, Kerala, and the Kyrgyz Republic, despite their modest levels of per-capita total health expenditures have delivered attractiveDALY Rateson account of their consistent prioritization of public-health interventions such as near 100% vaccine coverage levels and strong control of infectious diseases. Additionally, countries such as Turkey, Colombia, Costa Rica, Thailand, Peru, Nicaragua, and Jordan, have all delivered lowDALY Ratesdespite modest levels of per-capita total health expenditures on account of their emphasis on primary care. While, as can be seen from the discussion, several valuable conclusions can be drawn from this kind of analysis, the evolution of health systems is a complex journey, driven by multiple local factors, and a multi-country cross-sectional study of the type attempted here runs the risk of glossing over them. The study attempts to address these limitations by being parsimonious and simple in its approach toward specifying its quantitative models, and validating its conclusions by looking deeper into country contexts.

Introduction: Comprehensive primary care is a key component of any good health system. Designers need to incorporate theStarfieldrequirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach.Methods: We suggest that there are potentially four stages in the evolution of the CHW – the health messenger, the physician extender, the focused provider, and the comprehensive provider. In the latter two stages, the physician becomes much more of an adjunct figure, unlike in the first two, where the physician is at the center. We examine the comprehensive provider stage (stage 4) with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4Starfieldprinciples, we first arrive at 17 potential characteristics that could be important. Based on a careful reading of the six programs, we then attempt to determine the characteristics that apply to each program. Using this data, we look across all the programs to ascertain which of these characteristics are important to the success of these six programs. Using atruth table, we then compare the programs which have more than 80% of the characteristics with those that have fewer than 80%, to identify characteristics that distinguish between them. Using these methods, we analyse two global programs and four Indian ones.Results: Our analysis suggests that the global Alaskan and Iranian, and the Indian Dvara Health and Swasthya Swaraj programs incorporate more than 80% (> 14) of the 17 characteristics. Of these 17, there are 6 foundational characteristics that are present in all the six stage 4 programs discussed in this study. These include (i)close supervisionof the CHW; (ii)care coordinationfor treatment not directly provided by the CHW; (iii)defined referral pathwaysto be used to guide referrals; (iv)medication managementwhich closes the loop with patients on all the medicines that they need both immediately and on an ongoing basis (the only characteristic which needs engagement with a licensed physician); (v)proactive care: which ensures adherence to treatment plans; and (vi)cost-effectivenessin the use of scarce physician and financial resources. When comparing between programs, we find that the five essential added elements of a high-performance stage 4 program are (i) the fullempanelmentof a defined population; (ii) theircomprehensive assessment, (iii)risk stratificationso that the focus can be on the high-risk individuals, (iv) the use of carefully definedcare protocols, and (v) the use ofcultural wisdomboth to learn from the community and to work with them to persuade them to adhere to treatment regimens.

Introduction: Primary care is an essential component of any health system, but building high-quality primary care has proven to be a challenge for most developing countries. Among the multiplicity of providers in South Asia, one of the most ubiquitous channels through which not only medicines are obtained but also primary care advice is sought is the neighborhood pharmacy. There are widespread availability of pharmacies in South Asia. There is also good evidence that working with pharmacies in this way is a globally accepted idea, and there are several examples of countries, such as France and Nigeria, that have integrated pharmacies into their primary care systems and entrusted them with significant responsibilities.Methods: In this paper, we explore the potential of this channel as a formal primary care provider, with a particular focus on the South Asian context, by examining how pharmacies perform against the seven Starfield attributes of (i) first contact care, (ii) continuity of care, (iii) comprehensiveness, (iv) coordination, (v) family centredness, (vi) cultural competency, and (vii) community orientation. In the paper, we use data on pharmacies from four pharmacy-related interventions, one from Bangladesh and three from India, to carry out our analysis using the Qualitative Comparative Analysis (QCA) framework.Results: We find that even in the South Asian context, pharmacies provide several components of good primary care. As expected, they demonstrate a strong orientation toward the community in which they are located and are able to provide first-contact care. However, we find no direct evidence that they are able to offer continuity of care or bring to bear family-centredness and cultural competency when dealing with their patients. It is encouraging, however, that while there is no formal evidence of this in any of the interventions, multiple anecdotal examples suggest that pharmacists do indeed do much of this, but perhaps in an informal and inconsistent manner.Discussion: The evidence from these studies provides support for the view that pharmacies have many of the inherent characteristics needed to become an effective primary care channel and already play an important role in providing access to health information and care. However, it is also clear from the research that without additional training and access to tools, pharmacies will not have the competency or knowledge necessary to provide these services or even act as an effective gateway to other healthcare providers. To fully unlock this opportunity, therefore, any organization that wishes to engage with them will need to have the vision and patience to work with this network for an extended period of time and not merely aspire for incremental improvements but have a strategy in place that fundamentally changes the capabilities and the roles that pharmacies can play.