4 Ways India Can Aim For Universal Primary Healthcare

Mumbai: 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.

The Declaration of Astana makes four key pledges:

(1) make bold political choices for health across all sectors

(2) build sustainable primary health care

(3) empower individuals and communities

(4) align stakeholder support to national policies, strategies and plans.

“[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.”

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: 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.

The Declaration of Astana makes four key pledges:

(1) make bold political choices for health across all sectors

(2) build sustainable primary health care

(3) empower individuals and communities

(4) align stakeholder support to national policies, strategies and plans.

“[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.”

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.


2 responses to “4 Ways India Can Aim For Universal Primary Healthcare”

  1. I was there at Astana for the global conference on primary health care. Before we review the Astana declaration, we must look at the excellent background documents.

    https://www.who.int/primary-health/conference-phc/background-documents

    It’s not always that high resources guarantee better health care. There are enough successful models globally that have delivered excellent results within limited resources like Cuba and SUS of Brazil, and some with ample resources still far from expected outcomes.

    Next comes research articles, which we quote without critically reviewing it. Statistically significant doesn’t always mean that it is of clinical significance to the common public.

    I am worried about the comparison of RMA, Ayush and medical officers on selective criteria. Please understand that health care is more about team work providing coordinated, comprehensive, continuing quality care. Such comparison on selective grounds may not have much significance in light of the responsibility and different work profile of each member.

    Every team member should ideally work in sync to compliment the other’s work. Each member has their role and responsibility, which clearly is not replacement.

    Sadly, discussion has shifted to replacing doctor’s role with inadequate training in light of selective so-called significant research.

    Inequity in terms of health workforce, resources allocation as well as utilisation and rural-urban disparity is indeed a reality. We should consider and be careful when we judge India on global standards. Those standards may not be applicable in our context like doctor-population ratio.

    Looking at our population and our priorities, it’s really unfair, and sometimes unrealistic, to compare with global standards. Most data available are from the developed nations and are biased towards them.

    There are huge data gaps in LMICs. There is growing interest in research in LMICs but we need to be careful in interpreting the results because of our huge diversity, health standards, health-seeking behaviour and disease epidemiology. Most interesting in India is that health is a state subject, and there are different models across states.

    Isn’t it ironical that in a country where there is huge health care shortage, there isn’t a single recruitment for family doctors (family medicine) who are specially trained to strengthen primary health care – either in the much promoted PMJAY or in primary care settings of PHCs, CHCs and district hospitals? There are posts for gynecologists, surgeons and pediatricians but not family doctors who are trained to provide primary care services and act as gatekeepers providing comprehensive services to all age groups.

    Universal health care can’t be achieved without strong, sustainable and highest quality primary health care. There shouldn’t be any excuse for “Health for All”.

    PMJAY is an excellent initiative and should focus on “quality” to make it sustainable. We should prioritise primary health care over insurance for future gains. Investments in primary health care will reduce referrals to secondary and tertiary care.

    Sadly, we don’t have any referral policy. Gate keeping is missing and so are family doctors.

    We failed to achieve MDGs, and it should awaken policy makers to the limitations of vertical programmes. There needs to be horizontal integration without fragmenting primary health care. Quality health care can’t be delivered in silos.

  2. In India, I believe, the primary cause of TB is inadequate nourishment/ nutrition. This aspect needs more attention before “health care “ initiatives bear significant results.

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