Blog

A woman in labor develops a complication that requires urgent referral. The Auxiliary Nurse Midwife (ANM) attending to her recognizes the danger signs, follows the protocol, and initiates the referral. But the ambulance is unavailable. The nearest referral facility does not have the capability to manage the complication and the blood that may be required is not available. The woman does not receive the care she needs in time. 

Where, in this case, did the failure occur? Was it a gap in the ANM’s knowledge or skills? Did she fail to recognize the complication or act on it? Or did the breakdown occur elsewhere in the pathway that should have enabled her actions to translate into care? 

The answer matters because how we diagnose the problem determines how we try to fix it. When poor service delivery is attributed to health-worker performance, the distinction between a competency gap and a system constraint is often overlooked. As a result, training can become the response to problems it was never designed to solve. When a health program underperforms, a common response across ministries, donors, and implementing organizations is to retrain the health workforce. This instinct is not unreasonable. Human resources for health (HRH) are the point of contact between health systems and the people they serve, and their knowledge and skill genuinely matter. But the problem arises when we default to retraining without first understanding what is causing poor performance.   

This is not to argue that training doesn’t work. Where a cadre genuinely lacks the knowledge or skill a role requires, training closes that gap well. Evidence from Peru shows that training alone is not a sufficient intervention because it leaves untouched the deeper problems like attrition and weak supervision that shape how a worker behaves on the job. The question then is whether poor performance reflects a genuine competency gap or whether constraints elsewhere in the system are preventing the worker from performing effectively. 

Figure 1: World Health Organization’s (WHO’s) six building blocks of a health system

One lens to address this question comes from the WHO’s health systems framework (Figure 1). The framework’s emphasis on interconnectedness highlights that health-worker performance depends partly on how well the surrounding health system functions. This implies that a health worker’s performance is not something they generate on their own. It depends on whether their role is clearly defined, whether they have access to the medicines, equipment and information they need and whether the facilities and referral systems around them are capable to respond.  

A “system” failure hence is not a single black box. It is usually a chain of decisions, a district store that under-ordered, and a supervisor who never visited. Yet, it is often the health worker who absorbs the blame because they remain the most visible actor in that chain. A dysfunctional referral pathway, a non-existent supervision structure, or a deployment decision made several levels above them sit further back in the system and can therefore go unexamined and unaddressed. This also helps explain why retraining so often becomes the default response even when the actual constraint sits elsewhere in the system. 

The pathway from training to better service delivery, therefore, has several links: training must build competency, competency must translate into performance, and that performance must connect with a functioning service-delivery pathway. A failure at any one of these points can produce the same visible result: poor service delivery. 

Illustrative examples of where and how the system might break down 

1. Unclear roles: Before competency can be verified, there has to be clarity on what a health worker is expected to do. Without this clarity, we risk adding tasks and training to cadres without considering whether those tasks belong within their role.  Getting the right person, with the right competencies, to perform the right role, therefore starts with clearly defining what each cadre is expected to deliver.
2. Inadequate supervision: Even when roles are clearly defined, health workers may not receive the supervision needed to translate those expectations into practice. Studies consistently show that supportive supervision measurably increases direct patient care. In practice, however, supervision can remain focused on compliance rather than on assessing competencies, identifying performance gaps, and supporting workers to improve.  
3. Poor deployment: A well-trained and supervised worker cannot compensate for being posted in the wrong place. For instance, in Indonesia, only 4 of 38 provinces have one doctor per 1,000 people. The challenge, therefore, is not only the workforce size but how effectively it is distributed in relation to population need.  
4. Facility-level constraints: Even when the right worker is in the right place, performance can still be constrained by the absence of basic inputs. A trained health worker cannot deliver services effectively without the medicines and equipment required for their role. This holds particular relevance for Community health workers in low- and middle-income countries, who face stock-outs of essential medicines nearly one-third of the time.  

Together, these examples show how a performance gap that appears at the level of the health worker may originate elsewhere in the system. They are not exhaustive. Financing, workload and staffing, referral systems, technology, governance, and other system-level factors can similarly shape whether health workers are able to perform effectively. The specific constraint will vary across contexts, which is precisely why identifying where the performance gap lies must come before deciding how to address it.  

What actually moves the needle 

Rather than defaulting to training, the first step is to understand what is driving the performance gap and where in the pathway does it occur. The framework below provides a simple way to diagnose whether the constraint lies in the worker’s role, competency, enabling environment, ability to sustain performance, or the wider health system. 

A framework to identify where the performance gap lies in the health system:

Identifying where the performance gap lies is only the first step. The next is determining who is best placed to investigate its cause and act on it. This should not automatically be the actor closest to where the failure becomes visible. Instead, ownership of the diagnosis should follow three simple questions: 

For example, if a health worker is unable to demonstrate a competency required for their role, a supervisor or clinical mentor may be best placed to diagnose the gap. If trained workers across a facility are unable to deliver services because essential commodities are repeatedly unavailable, the diagnosis needs to involve facility and district management. If patients are consistently lost between referral points, the district or program team may need to bring together the actors responsible for referring, transporting and receiving patients. Where the same deployment, financing, or governance constraint recurs across multiple districts, diagnosis may need to move further upstream to the state or national level. 

The principle is simple: the actor at whom a problem becomes visible should not automatically become the actor held responsible for diagnosing or fixing it. The person who experiences the constraint, the person best placed to diagnose it, and the person with the authority to address it may all be different actors. 

Conclusion 

The aim is not to train less, but to diagnose better. Not every performance gap is a training gap, and the actor closest to the problem may not always be the best placed to address it. When service delivery falls short, the first task is to understand where the pathway is breaking down, what is causing the gap, and who is best placed to act on it. 

The diagnosis should then guide the programmatic response. A competency gap may require training, an unclear role may require role redesign or clearer responsibilities, an enabling gap may call for better supervision, deployment, commodities or tools, and constraints in the wider system may require changes to referral pathways, financing, governance or coordination. The value of the framework is therefore not simply in identifying the problem, but in helping programmes match the right intervention and the right actors to the gap they are trying to solve.  

Introduction

India is aging at a pace that will test the capacity of its health and economic systems. In 2022, 149 million Indians were aged 60 and above, about 10.5% of the population; and by 2050, there will be 347 million, or 20.8%.

The elderly population is currently growing at a decadal rate of 41%, faster than any other age group. Older adults will likely outnumber children aged 0–15 by 2046. After decades of planning for a young and growing population, India must now prepare for rapid aging. The country must also ensure that people live these years in good health, with financial security, independence, and dignity.

Population aging in India currently appears as a future welfare burden, but it is an urgent economic policy challenge. The case for investing in healthy aging rests upon proactive systems. These systems protect households, sustain labor markets, improve productivity, and support continued contribution in later life. They also challenge the assumption that aging inevitably leads to dependency.

These economic gains will largely come through two complementary pathways: the reduction of losses from poor health and disability in later life, and the creation of new value through support that helps older adults remain healthy, active, and independent for longer.

Reducing the economic losses of unhealthy aging

The first gain from investing in healthy aging comes from lowering the costs of poor health in later life. Despite advances in financial protection and health assurance, out-of-pocket expenditure continues to account for 43.4% of total health expenditure in India. This burden falls heavily on the elderly. An older adult spends roughly 17.4% of total household consumption on healthcare, a share that rises to nearly a quarter (24.8%) among the poorest of older adults.

For many families, a serious illness in old age can deplete savings, force the sale of productive assets, or push entire households into debt. Families divert savings that could support education or enterprise investment to medical expenses instead. The economic consequences extend well beyond the health sector. They affect household consumption, generational asset creation, and long-term financial security.

Much of this burden is preventable. Investments in preventive care, early diagnosis, and effective management of chronic conditions reduce the likelihood of expensive hospitalizations and complications, generating savings for both households and the health system.

Healthy aging is about more than just extending lifespan. It is about increasing health-span, the years people live free from significant illness, disability, or functional decline. Ultimately, it is also about enhancing joy-span, which includes purpose, social connection, autonomy, and emotional well-being.

Healthier, more independent years mean lower treatment and long-term care costs for both families and the health system.

Creating economic value through healthy aging

The economic case extends beyond healthcare cost reductions. As the population ages, demand for informal, unpaid caregiving rises. Women bear most of this burden and often leave paid work to provide care. Globally, one year away from paid work leaves women with 42% less in retirement savings, rising to 56% after five years of interrupted employment.

Healthy aging also expands the productive contribution of older adults. Traditional assumptions often portray older people as dependents. Yet, nearly 40% of Indians aged 60 years and above remain economically active, particularly through agriculture, self-employment, household enterprises, and the informal economy. Older adults also take on childcare and household management, work that is essential to families but has historically gone unpaid. These forms of work generate substantial economic value, despite their limited recognition in national accounts.

Preserving functional capacity and independence helps older adults and their families to remain active participants in the economy.

Why the opportunity is greatest now

India is younger than many countries that already face the fiscal pressures of population aging. In 2021, the country had roughly 16 older adults for every 100 working-age people. This demographic window gives India fiscal and institutional space to invest in healthy aging before these pressures intensify. Early investments in the aging-friendly interventions can compound over time.

Vietnam offers a close parallel. Its intergenerational self-help clubs, launched in 2006, began as older people’s associations before they expanded to include the wider community. These voluntary village-level groups have 50–70 members and combine health monitoring, livelihoods, and social participation. These clubs focus on older people, women, and those facing economic hardship. This award-winning model costs little and transfers easily because it uses existing community structures.

Fortunately, India does not need to build an entirely new system. The Ayushman Arogya Mandir network, community health workers, and digital health platforms like eSanjeevani already support preventive, continuous, and community-based care.

Older adults also benefit from dedicated government programs such as Atal Vayo Abhyuday Yojana, Elderline, Senior Able Citizens for Re-Employment in Dignity (SACRED), and Seniorcare Ageing Growth Engine (SAGE). In addition, the expanded Ayushman Bharat coverage now supports citizens aged 70 and above.

The foundations already exist. The challenge is to integrate existing health, aging, and digital systems into a coherent strategy that prioritizes prevention, functional ability, and healthy aging across the life course.

The choice: Spend now or pay more later

India will incur the costs of population aging regardless of its policy choices. The real question is whether it pays those costs proactively through prevention, early intervention, and community-based care, or reactively through hospitalization, disability, and crisis-driven spending.

Healthy aging is often framed as a social responsibility, and it most definitely is. But it is also an economic strategy. For a country entering one of its largest demographic transitions, adding years to life is no longer enough. The greater challenge and opportunity lie in adding joy, dignity, social participation, and care to those years. Whether longer lives weigh on the economy or add to it will depend on the choices India makes now.