India has to move from vertical to comprehensive programmes, improve quality and access, hire more mid-level health workers and increase funding to improve primary care for achieving universal health coverage, public health experts told IndiaSpend.
That health is not “merely the absence of disease or infirmity”, but “is a fundamental human right” was proclaimed 40 years ago in the Alma-Ata declaration in Kazakhstan in 1978. On October 25 and 26, 2018, the declaration was reiterated by 197 countries around the world as they signed the Declaration of Astana that vowed to strengthen primary healthcare as an essential step for achieving universal health coverage.
India, also a signatory to the Astana declaration, has to strengthen primary healthcare if it has to achieve health for all since it accounts for 17% global burden of maternal deaths, the highest number of tuberculosis cases and deaths in the world and the highest number of stunted children in the world. As many as 55 million Indians slipped into poverty in 2011-12 because of health catastrophes they could not afford.
“[Astana declaration] is very important for not just India but the world as a whole to be reminded of the importance of primary healthcare as the foundation of a health system and as the critical component for achieving universal healthcare. It’s a timely reminder,” said K Sujatha Rao, former union secretary of health, public health expert and author of Do We Care: India’s Health System.
Shift from vertical programmes to holistic care
Even though the Alma Ata declaration called for global commitment to comprehensive primary health care in 1978, donor-driven programmes steered low and middle income countries towards ‘selective healthcare’ focussing on a few diseases and health needs, said K Srinath Reddy, president, Public Health Foundation of India, a think-tank and research institute.
Even the millennium development goals focussed on select targets and fragmented the health system into vertical disease programmes and segmented health services for specific diseases and age groups.
For example, 55% of the ministry of health and family welfare budget in 2018-19 was for the National Health Mission, of which maternal and child health component accounted for 74%. This despite the fact that non-communicable diseases such as hypertension, cancer and diabetes killed 61% Indians in 2016.
“The lessons of the past 40 years have taught us that vertical programmes, however nobly intended and well designed, cannot be force fitted in to a weak health system,” said Reddy.
India has taken steps to address the gap and included comprehensive primary healthcare in National Health Policy 2017.
An important component of the Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (National Health Protection Scheme) is the health and wellness centres--sub-centres and primary health centres that will be converted to provide comprehensive care for communicable and non-communicable diseases.
“If implemented, this (health and wellness centres) can be a game changer,” said Rao. “I feel this should have been accorded high priority and sequenced to be achieved before launching the hospitalisation aspect of Ayushman Bharat.”
Health systems have to be built incrementally, and hospital insurance in India’s context is likely to be overwhelming and drain resources from primary healthcare, she added.
Improve quality of care and reduce barriers
Indian healthcare killed more people due to its poor quality than due to lack of access. In 2016, 1.6 million Indians died due to poor quality of care, almost double than those killed due to non-utilisation of health services (838,000), IndiaSpend reported in September 2018.
The current standard of sub-centres and primary health centres is poor and ill-equipped to take care of the needs of India’s growing population.
Sub-centres are at the forefront in providing healthcare at the local level; however 73% sub-centres were more than 3 km from the remotest village, 28% were not accessible by public transport and 17% were unhygienic, IndiaSpend reported in a two-part series (here & here) in August 2018.
In 24 states, instances of non-availability of essential drugs were observed by an audit by Comptroller Auditor General (CAG). Further, there was a 24%-38% shortfall in the availability of medical personnel at primary health centres, sub centres, and community health centres in 28 states/union territories of India, CAG found.
This makes a large number of citizens--58% in rural areas and 68% in urban areas--to seek care from the private sector though it may not be any better in quality.
Implementing the Clinical Establishments (Registration and Regulation) Act (that is adopted by over 20 states) to set in standards and monitor the private sector may help in this aspect, Reddy had told IndiaSpend earlier. Also, having a composite health quality assessment system in place will bring in more transparency, he added.
Empowering and implementing Rogi Kalyan Samitis (patient welfare committees) that use community participation for improving facilities in public hospitals can also make a difference.
Pay and train frontline workers better, hire mid-level health workers
India’s over one million Accredited Social Health Activists (ASHAs), who are the frontline health workers, are inadequately trained and are underpaid.
About 70%-90% ASHAs said they needed better training, monetary support and timely replenishment of the drug kit to perform better. Only 22% ASHAs surveyed had some understanding of their role, IndiaSpend reported in May 2016.
ASHAs are now paid a honorarium of Rs 2,000 a month--equivalent to the cost of an up-market meal for two--up from Rs 1,000 from October 2018.
Poor living and working conditions, irregular drug supply, weak infrastructure, professional isolation and the burden of administrative work make working in rural areas difficult for doctors. This explains why there are 1,974 primary health centres without doctors and why 39% medical providers in PHCs in 19 major states were counted “absent”.
One alternative to meet the healthcare needs of rural population is training and employment of mid-level healthcare staff, also known as community health workers.
In one such initiative, in Chhattisgarh, rural medical assistants (RMAs), a special cadre of health providers trained for three-and-a-half years, were inducted into the state’s health workforce to fill the gaps created by vacancies for medical officers in PHCs.
It was found that RMAs performed the best in terms of prescribing drugs, and the perceived quality scores were the highest for RMAs (85%), followed by medical officers (84%), AYUSH medical officers (80%) and paramedicals (73%), IndiaSpend reported in October 2018.
“We need to increase the numbers, skills, salaries and social status of community health workers, auxiliary nurse midwives, nurse practitioners and community health officers trained in a three-year programme,” said Reddy.
“We should equip and train them in easy-to-use technologies adapted to point of care diagnostics, decision support systems and tele-consultation,” he added. “They should become part of village and block level health planning and monitoring process and be enabled to become the trusted community connects of the health system.”.
Spend more on health
India spent 1.02% of its gross domestic product (GDP) in 2015--a figure that remained almost unchanged in six years since 2009. Also, India’s public health expenditure is amongst the lowest in the world, lower than most low-income countries which spend 1.4% of their GDP on health, IndiaSpend reported in June 2018.
The money India spends on public health per capita every year is Rs 1,112, less than the cost of a single consultation at the country’s top private hospitals or roughly the cost of a pizza at many hotels and about Rs 93 per month or Rs 3 per day.
This increases the share of out-of-pocket (OOP) expenses for Indians, and have made Indians the sixth biggest OOP health spenders in the low-middle income group of 50 nations.
The National Health Policy 2017 talked about increasing public health spending to 2.5% of GDP by 2025, but India hasn’t yet met the 2010 target of spending 2% of GDP.
Despite greater investment in health with Ayushman Bharat Scheme, it may not necessarily lead to greater improvement in primary care if stacked against expensive hospital insurance model, said Rao. “India has never spent more than 1.2% of GDP for health,” Rao said. “Primary healthcare alone needs 1% of GDP to bring it up to some standards. So unless there is a significant increase in health budgets, choices will always favour hospital insurance.”