BACKGROUND Indiaās health systems reform journey has been marked by institutional innovations that have reshaped service delivery, governance, financing, and beyond. Among these, a foundational yet often overlooked innovation is the creation of a structured ecosystem for health policy guidance: a network of State Health Systems Resource Centres (SHSRCs), supported by the National Health Systems Resource Centre (NHSRC). These institutions were not intended as parallel implementation units. Rather, they were envisioned as embedded policy advisory bodies that are intended to synthesize evidence, support strategic planning, and enable system-wide reforms. While NHSRC continues to serve as the apex technical institution supporting the Ministry of Health and Family Welfare (MoHFW), the SHSRCs were designed to play a decentralized and synergistic role within states. However, they remain variably recognized and underutilized. Unlocking their full potential could substantially enhance the capacity for state-level, evidence-informed decision-making and strategic design. AN INSTITUTIONAL DESIGN WITH PURPOSE Established in 2007, NHSRC functions as the principal technical support agency for MoHFW, with a mandate that includes policy and strategy development, technical assistance to states, and capacity building under the National Health Mission (NHM). Over time, it has played a pivotal role in institutionalizing quality improvement processes, advancing health financing reforms, guiding human resource strategies, strengthening secondary care and governance, innovations in community processes, and improved primary health care. Its enhanced role over the past 5 years, particularly through expanded expertise in evidence generation, implementation research, and the information technology realm, has been well appreciated and acknowledged. The SHSRCs, supported under the NHM and guided by NHSRC, were first envisioned under the National Rural Health Mission as in-house technical institutions to support health systems strengthening and policy development, particularly in the Empowered Action Group states.[1] However, their formation varies widely. Maharashtra and Madhya Pradesh, for instance, have established autonomous SHSRCs with independent governance and operational flexibility. Others, like Kerala, have adopted a fully embedded model within the state health department, with no legal autonomy but strong proximity to decision-making. Gujarat has adopted a hybrid approach, combining knowledge management cells, technical support functions, and programmatic units aligned with NHM priorities. In Chhattisgarh, the model transitioned from a registered society to an outsourced publicāprivate partnership structure. Newer entrants like Meghalaya illustrate growing development partner involvement in SHSRC functions through philanthropic support. In the absence of a unified design, this diversity has led to fragmentation in roles, mandates, and institutional identity. To address this, the MoHFW released a national SHSRC Framework in 2024, formalizing key principles of governance, technical leadership, and accountability.[2] The framework aims to guide states in repositioning SHSRCs as embedded policy support institutions that are context-specific yet aligned with national health priorities. AN UNEVEN LANDSCAPE OF UTILIZATION Despite the clarity of this institutional design, the operational landscape of SHSRCs across India remains uneven. While some centers have emerged as credible partners to their state governments, others face challenges ranging from intermittent staffing and fragmented mandates to unclear positioning within state bureaucracies. In several instances, donor-funded Technical Support Units (TSUs) have taken on overlapping roles. These arrangements may address immediate programmatic needs but often lack the institutional continuity, embedded authority, and public accountability required for long-term reform.[3] Overreliance on donor-funded TSUs risks fragmenting institutional ownership and accountability, weakening the stateās own capacity to generate and use evidence for policy guidance. Recognizing these risks, NHSRC has begun working with state governments to revitalize SHSRCs and help align them with national and state-level priorities, while safeguarding their role as government-owned and state-anchored policy advisory bodies. EARLY EVIDENCE OF WHAT WORKS Where SHSRCs have been clearly institutionalized, their contributions to health policy and systems strengthening are evident. In Chhattisgarh, SHSRC was central to the design and implementation of the Mitanin program, which later became the foundation for the national ASHA model. Its positioning as a public, in-house technical agency enabled long-term continuity, responsiveness to state-specific challenges, and innovation uptake.[4] In Odisha, the SHSRC has supported district health planning, capacity building, and institutional development initiatives across program areas. In Tamil Nadu, it has supported quality assurance mechanisms and monitoring systems within the health department. These cases suggest that, when adequately structured and supported, SHSRCs can serve as trusted intermediaries that connect evidence, program strategy, and systemic reform. STRENGTHENING SHSRCS FOR HEALTH POLICY GUIDANCE For SHSRCs to fulfil their intended role as policy advisory institutions, four strategic actions are necessary. First, states must clearly define the mandate and governance of SHSRCs based on the MoHFWās framework. This includes formalizing their distinct identity from TSUs, clarifying reporting structures, and embedding them within state health departments with a long-term vision. Second, sustainable financing should be assured through NHM provisions to reduce dependence on external actors. While TSUs may continue to serve specialized programmatic functions, they should not be equated as substitutes for in-house capacity. Third, investment in technical leadership and multidisciplinary staffing is essential. SHSRCs must attract professionals across epidemiology, public finance, implementation research, health systems, and data analytics. These are all disciplines critical to robust policy guidance. Establishing leadership structures that ensure continuity and accountability will further enhance operational coherence and effectiveness. Fourth, SHSRCs should continually expand their engagement with emerging health system interventions and institutionalize mechanisms. This includes supporting research, evaluation, and evidence-based decision-making. Their potential as platforms for resource optimization and collaboration with academic and public health institutions remains significantly underleveraged. NHSRC, through its existing mandate, can continue to play a catalytic role in this transformation by facilitating peer learning, technical handholding, and capacity strengthening. A STRATEGIC ASSET FOR THE NEXT PHASE OF REFORM As India deepens its health system reforms through initiatives such as Ayushman Bharat, and ongoing programme interventions under NHM, the need for decentralized, embedded policy guidance becomes more urgent. SHSRCs are already positioned to fulfil this role, not as supplementary structures but as enduring public institutions grounded in local systems and aligned with national goals. The imperative now is not to create new structures but to recognize and invest in the institutional capacities already in place. Authorsā contributions Maj. Gen. (Prof) Dr Atul Kotwal: Conceptualization; Writing ā Original Draft, Writing ā Review and Editing; Supervision. Dr Tarannum Ahmed: Conceptualization; Writing ā Original Draft, Writing ā Review and Editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest to declare.
Abstract This chapter offers an in-depth look at health politics and the universal health system in Poland, financed through social health insurance. It traces the development of the Polish healthcare system under communism, characterized by a complete shift from an insurance system to a state-run Soviet Semashko model of healthcare with some elements of private provision. Since 1989, Polish health policy went through systemic changes which included a shift to a decentralized social health insurance system in the late 1990s and re-centralization in 2001. Polish healthcare politics has been turbulent, marked by political instability matched by a dense network of veto points, including the President and the judiciary, that had an impact on the direction of health reforms. As the chapter highlights, some of the main issues have been high out-of-pocket payments, corruption, and privatization and commercialization of public hospitals.
The issue of hospital autonomy has aroused considerable international interest since the mid-1990ās, especially with regard to its linkage to governmental decentralization processes and reform of the health ļ¬eld. Non-proļ¬t hospitals have increasingly been obliged to become more autonomous as they compete for funding with private institutions. Objective: to understand how autonomy expresses itself through key management processes in non-proļ¬t and for-proļ¬t hospitals both in MedellĆn, the second largest city of Colombia, and its metropolitan area. Different institutional factorsāpolitical, administrative and economicāinļ¬uencing autonomy are examined. Methods: a grounded theory method was used, consisting of semi-structured interviews with managers in six hospitals. Results: ļ¬ndings suggest that autonomy is perceived more as an ideal to aspire to, which would enable the hospital management to make free decisions, providing services in a manner that ensures ļ¬nancial sustainability. In practical terms, however, the degree of administrative and ļ¬nancial autonomy is circumscribed by both internal organizational factors associated with hospitals characteristics and external factors associated with institutional environment.
I was in bed when Christopher Middleton first entered my life. I had been sequestered there for almost a month with a refractory spine. The drugs I took, pure codeine at one point, were such that I wept through the whole of World Championship Darts, so moved I was by those Apollonic figures, a band of ogres really, on the flickering television screen, and also by those sacrificial helpings of chips, sausages and baked beans that the audience consumed at their beer-towered tables. It was an aspect of English life that had completely bypassed me. The doctor, finding me in this blissful state, instantly put me on a duller regime. I was forced back to poetry. My literary life, insofar as I was able to pursue one, for my eyes swam all over the page, comprised a small pile of Middleton's books on the floor beside me. It was, in truth, my earliest acquaintance with his work, in particular the handsome 1969 Fulcrum Press edition of Our Flowers & Nice Bones. (Oh my, he's got a brain for titles.) I do not wish to give the wrong impression here, for Middleton is primarily a man of words, of words exquisitely bound together, but in my drugged state I was peculiarly receptive to his poem Birth of Venus, which reads in full: V V V V V V V V V V V V V V V V V V V V V V Could I really have been pondering the absence of that single V, finding in this something at once symbolic and full of erotic promise, when my wife came in and dropped in front of me a letter postmarked Austin, Texas? I looked at the sender's name and address and then I glanced at the volume beside me. This, surely, was proof enough that I'd reached a purely hallucinogenic stage of my existence. I do not wish to beat on about the zeitgeist or the want of one or about how whatever it is we're slumming our way through now is notable for its absence of generosity, especially in literary matters, but here, giving me succour when it was most needed, was a letter from a stranger full of kind words about a poem of mine he had read in a magazine. The impression this made upon me, especially in my physical state, was incalculable. One should not make too much of a man's age, but it is rare to find poets of Middleton's years and stature giving unsolicited encouragement to poets younger than themselves. I think this also has to do with Middleton's own youthfulness, which, in his work, is characterised by restlessness for and a desire to stake out new territories. Age does not deter him--juvenescence excites. Could he be one of the few to have properly understood Pound's injunction: MAKE IT NEW? I believe so, for what he writes is a matter of what he requires; it is born of necessity: there is no concession to prevailing modes. The letter marked the beginning of a friendship whose rewards, for me, have been immeasurable. A few months later, in the summer of 1992, Middleton came to England and to supper at our place. I shall record these first impressions of the physical man because, to some degree, they mark the interior one as well. There is a curious manner to how he walks, almost as if he were wearing bedroom slippers, a sort of floating aspect to him, and, quite frankly, the impression he made was one of a rather cool dude. A medallion hung from around his neck and the belt buckle he wore was as large as a horseshoe. Well, I might dissemble a little. If the man who soft-shoed into our lives was a Texan of one's imagination rather than of the real world the manner and voice were English in a way most English people no longer remember how to be. I have never had the opportunity to observe him in his adopted milieu, of course, so perhaps I am mistaken. It may be that he orders his glass of milk with a drawl and that tumbleweed does indeed tumble through the streets of Austin. What a strange and equally not so strange place for him to be. I am sorry to dwell at such length upon a man's attire and how it conceals the man inside, but I think there is some aspect of this in Middleton's writing: the precise English that comes of a fine education, such as this country offered once upon a time, dressed up in some fairly exotic clothes. ā¦
The British National Health Service (NHS) has, since its inception, aimed to make health care available to all regardless of income, and it has managed to achieve this goal while keeping costs lower as a proportion of the gross domestic product than many Western countries and at the same time assuring equitable distribution of resources regionally. Until the reforms introduced by the 1989 White Paper, the NHS was characterized by centralized financing and regulation; despite some problems in the delivery and management of care, the system was a popular one. The new reforms hope to enhance efficiency in the NHS by stimulating competition and further decentralizing the management of health care. However, it is not at all certain that in practice the reforms will have the desired effect. Initial costs will be high, people may not respond to incentives as predicted, and the quality of care and access to it could well deteriorate. Nations planning to use the U.K. system as a model are advised to use caution.
Italy now ranks 8th in the list of countries worst hit by AIDS. The relatively low figures for homosexual AIDS cases give no cause for complacency. It is not known yet if the message about 'safe sex' has got across to homosexuals, or if there has been underreporting and the numbers with AIDS will start soon to show the same rising curve as that for drug users. The Vatican, as was always expected, has said 'no' to the use of condoms to combat the spread of HIV, even though its use would not be to avoid conception but to prevent disease. Many doctors working in the field resent the lack of consultation and communication between Rome and the regions. But Italian health services are decentralized; the 21 regional health authorities are autonomous bodies. They have never looked to central government for specific directions, but they do desperately need extra funding. Their literature has been important as means of countering 'disinformation' from the press, often prone to sensationalism. Discrimination against children of parents infected with HIV has occured in schools and frequently seropositive employees have been fired. Local authorities are now making great efforts to impart the correct information. The Italian family planning association, UNICEMP, plays a supportive role in the education and information campaign. Many voluntary organizations provide counseling. The government national commission on AIDS set up a free telephone service where experts are available to answer questions from the public. But although 18,000 calls were made in the 1st 6 weeks of opening, hardly any inqueries at all came from those most at risk--the drug users.