It’s time to reimagine primary healthcare as a robust complement to Ayushman Bharat and other big-ticket initiatives
Anand Krishnan | July 5, 2018
The Ayushman Bharat health protection scheme, which aims to help the poor with an annual health insurance cover of Rs 5 lakh per family, has taken up a lot of media space, relegating health and wellness centres (HWCs) to the background. The chief criticism of the insurance-based scheme is that it will weaken the public healthcare system and favour private sector hospitals. Also, the government’s initiative to establish AIIMSes in many cities and towns is causing concern that its focus is on tertiary care at the cost of primary- and secondary-level healthcare. The HWC scheme is aimed at addressing these concerns and restoring the balance.
The concept of primary healthcare as opposed to primary level of care (first level of care) is more comprehensive and was first articulated in Alma Ata in 1977. It included principles like universal access, community participation, scientific soundness of interventions, affordable healthcare, and inter-sectoral co-ordination and called for ‘Health for All’ (HFA) by 2000. These socialist principles are still valid. However, operationalising these principles was, and is, not easy. In the eighties, for operational purposes, the concept was simplified by focusing on delivering a selected package of services, mainly related to maternal and child health (MCH). We also erred in pitting primary healthcare as a low-cost alternative to hospital care and to be delivered by non-professional healthcare worker using simplified protocols. In a way, it amounted to low-quality care for the poor. Primary healthcare was rediscovered by the World Health Organisation (WHO) in 2008, on its 30th anniversary, and it proposed a set of reforms and called for more robust but inclusive government involvement in healthcare (as opposed to laissez-faire disengagement).
When India launched its National Rural Health Mission in 2005, it had addressed many of these issues and it marked one of the most ambitious upgrades of our health system. With this, the resource envelope available for health increased dramatically, while still short of what is required. Today, we can choose to be ambitious – that is, think of Universal Health Coverage (UHC). This is also in keeping with what WHO is currently promoting. One cannot miss the similarity between ‘Health for all’ and UHC.
With increased resources and a global push for UHC, it is time we reimagined our approach to strengthening healthcare and promoting health in India. The proposal of implementation of comprehensive primary healthcare (CPHC) package through the HWCs is the first step in substantially reimagining and improving the lowest rung of our health system catering to urban poor and rural areas.
As a part of the CPHC, 12 components (including oral care, trauma care and so on) have been identified. An information technology-based architectural backbone is being established which will make integration across these components possible. Like MCH earlier, this time around non-communicable diseases (hypertension, diabetes, oral/breast/cervical cancers) are the entry point for CPHC. The other 11 components would be implemented in phases once the delivery platform is ready. The HWCs are conceptualised as transformed sub-centres that provide a package of services through a combination of home visits, outreach, and facility-based services. The post of mid-level health provider (either a nurse or an ayurvedic practitioner trained for six months in a bridge course) has been created to lead teams of existing workers. Its implementation will require major changes in the organisation of services, in allocation of work and technical competencies required, in work processes, in reporting information and monitoring, in financial flows, etc. This column reviews some specific components of this scheme which has raised concerns among the public health community.
A major concern has been related to the introduction of a new cadre. There is enough global and Indian evidence that such mid-level practitioners can be trained to manage most cases of chronic illnesses like hypertension and diabetes with a mobile phone-based decision support system and with referral linkages with higher levels of health system. This improves accessibility to care and reduces cost both to the patient and to the health system. These care providers are also expected to promote healthy habits by advising on yoga and lifestyle changes. Thus, while this is a welcome step, any addition of a new post in the national health system must be well thought out. While in the short term, they may be contractual, in the long-term they should form a new cadre in the health sector with promotions up to district level. Apart from many consequent human resource-related issues, our experience shows two major problems with these kinds of mechanisms for human resource: many of these mid-level cadres would leave the service to start their own practice (as unqualified practitioners?); secondly, usually curative care takes precedence over promotive and preventive care, as that is the felt need of the community.
The government is pushing at its implementation very hard, though ventures of this sort require much more time for planning and implementation. The hurry, it seems, is for political gains as elections near. It is indeed an occasion for celebration that a health issue is on the political agenda. However, caution is warranted, as we know that speed thrills, but kills. Pushing too hard would lead to adoption of shortcuts and that is not good in the long run.
Most sub-centres were built with World Bank funding under the India Population Projects about two decades back with very little routine maintenance being done in the interim period due to lack of engineering funds and coordination. Lack of safety, water and electricity supply plague these sub-centres. Currently there are about 1.5 lakh sub-centres for healthcare in India and with a proposed increase in services, we may require new buildings and a major infrastructure upgrade requiring lots of funds. It might be worthwhile for us at this stage to redesign sub-centres and invite open bids for designing sub-centres that are environment friendly (solar-based), low-cost, disabled friendly, etc.
To expedite implementation, there have been discussions on outsourcing options as well – to the not-for-profit sector at this stage. It would be prudent to set up a good monitoring mechanism before such outsourcing is done as accountability has never been our strong point. While increased allocation to primary care is welcome, it is hoped that the government will not gradually withdraw from higher levels of care and leave it for private sector to be addressed through the other component of Ayushmaan Bharat.
Overall, the reaffirmation of socialist goals by a right-of-centre government is heartening. Strengthening primary care is very much needed and it will have to be based on non-MBBS care providers. Both from the equity point of view as well as from the resource allocation point of view, these initiatives are and should be welcome. While there may be some valid concerns, I see newer opportunities and major long-term gains. In conclusion, the journey is long and arduous, but the destination is worth it and course correction can always happen along the way, as long as we are ready to listen and learn.
Krishnan is professor of community medicine at the All India Institute of Medical Sciences, Delhi. The views
expressed here are personal.
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