Public Health System Performance Challenges in India : A Systems Thinking Approach

Public health is a means of preventing disease and providing curative care to promote citizens' health through organized efforts of various stakeholders. Performance challenges in public health in developing countries continue to surround access, availability and quality. The public health system in India is plagued additionally by under-investment, sub-optimal utilization of resources and failure of accountability in general. These have resulted in uneven use of curative facilities and increasing out-of-pocket expenditures intensely disfavoring economically weaker citizens. Using systems thinking approach, we identify the different constituents of public healthcare system in India and their interlinkages. We qualitatively map the underlying structure to two specific systemic behaviors – the excessive use of referrals and, the co-occurrence of overburdened tertiary care centers and the under-utilization of primary care centers. The analysis draws upon the ‘fixes that fail' and ‘shifting the burden' archetypes in system dynamics to argue the need for more fundamental solutions to resolve performance challenges in public healthcare system in India