Moving on from Primary Health Care

People waiting to get registered at Motihari District Government Hospital in East Champaran, Bihar. With so few doctors employed to work in the public sector of healthcare in India, this scene is typical.

Primary health care is an important strategy which is the backbone of health service delivery. Primary health care is the day-to-day care needed to protect, maintain, or restore our health. For those who use it, it is both their first point of contact with the government healthcare system and their most frequently used health service. In last 6 decades of independence, we have seen much improvement in primary healthcare services, infrastructure, and related healthcare indices of the country. Still, many challenges are ahead to achieve health for all and there is a need to review primary health care in the country to know our strengths and weaknesses to face the challenges in the future.  But soon, unfortunately, the Primary Health Care system we have known all our lives, warts and all will disappear. What will come into being is the concept of Universal Health Coverage (UHC), now enshrined in the Sustainable Development Goals, replacing the Primary Health Care notion we have grown up with.

Soon we will have wellness centers instead of Primary Health Centres as envisaged in the National Health Policy of 2017 as UHC begins to get rolled out. The policy expresses the specific need of providing healthcare in the far-flung corners of the country through upgraded sub centers by converting them into Health & Wellness Centres. The 2018 – 19 budget has allocated Rs1,200 crore for converting 150,000 sub-centres into active delivery hubs for comprehensive primary health services which encompass community-based health promotion, disease prevention, basic diagnostic and treatment services for common clinical conditions including non-communicable diseases and mental illness. While this is very welcome, the major challenge will be in recruiting and retaining the required number of skilled health personnel in these centres. Unless the allocation for the National Health Mission is ramped up, non-availability of front-line health workers will remain a barrier for revitalizing primary health services. The List of Services provided through these health & wellness centers is exhaustive and is as follows :

  • Pregnancy and Child Birth
  • Neo-Natal and Infant Health
  • Childhood and Adolescent Health
  • Family Planning and Reproductive Health
  • Common Ophthalmic and ENT Problems
  • Oral Health
  • Mental Health Ailments
  • Elderly and Palliative Health
  • Emergency Medical Services
  • Management of Communicable Diseases
  • General out-patient Care
  • Non-Communicable diseases
  • Health Promotion using Yoga
  • Free essential medicines
  • Free diagnostics facility
  • Teleconsultation
  • Robust and Secure IT System
  • Cashless Benefits through Health Cards
  • Electronic Health Records

The role of the doctor and specialist will be extended from making a diagnosis and treatment plan to ensuring medication compliance for chronic illness and follow up care delivered close to home. The health and wellness centres are currently designed to cater to 3,000 to 5,000 people with three nurses or paramedical workers. Access to health care which is affordable and readily accessible and sufficient in terms of human resources and infrastructure is a major challenge in rural areas and overcrowded urban areas and the wellness centres are meant to address this issue.  It is also meant to address the cost of care issues, which is a major challenge in a system where patients and families have to bear the burden of high out-of-pocket spending for treatment.

Human resources and infrastructure will, however, be a big challenge. The contrast is quite remarkable—on one hand, we have made rapid strides in medical technology, and have top quality doctors to the extent that we are promoting medical tourism even amongst developed world patients, on the other 70% of India’s population in rural areas has very limited access to quality healthcare facilities. Primary health centres have seen a substantial jump in numbers. However, they are faced with a shortage in terms of doctors, nurses, specialists and even medical equipment.  Even in urban areas, the healthcare facilities are not enough to take care of the country’s burgeoning requirement. Over 63 million people in India are pushed to poverty every year due to health care costs. In India, the number of hospital beds per thousand people is at a paltry 0.7 as against 3.8 in China. Similarly, the number of doctors per thousand people is 0.6 versus 1.8 in China. The share of government in the total expenditure on healthcare is at a low of 30.5% in India compared to 77% in Thailand, and 55% in China. Among the developed countries, the UK and European countries have a high public expenditure at around 75-80% of total health expenditure.

The problem is seen when we look at India’s spending on healthcare, Central Government and State Government combined, which is substandard for a growing country like India. According to Lok Sabha Question No. 1317, the expenditure on healthcare as a percentage of the GDP for the last three years is –2014-15 – 1.2%, 2015-16 – 1.4%, 2016-17 – 1.5%. The National Health Policy envisages increasing public expenditure on health to 2.5% of GDP in a time-bound manner by 2025 which is a very slow rate of increase. Unfortunately, therefore India also has one of the highest OOP (out-of-pocket) expenditures in the world as facilities provided by the government are inadequate. The government’s own figures mention that our citizens spend one of the most on healthcare (and certainly do not get the equivalent quality). We rank 182 out of 192 in terms of OOP expenditure as a percentage of total health expenditure. This shows the wide gap we need to overcome to provide universal healthcare for all our citizens.

Secondary and Tertiary care is proposed to be handled separately through the National Health Protection Scheme, called Modicare in the popular jargon and is meant to be insurance based. That needs to be examined separately. But it is worth noting that these insurance packages lead to public tax money being invested in private health insurance companies, rather than being put back into government funds, where it could be used to, for example, improve the primary healthcare infrastructure and healthcare workforce in rural areas.

Shantanu Dutta is a former Air Force Officer and a development worker for the last 25 years and more.


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