By Sukanya Bhaumik
This World Health Day, the World Health Organization (WHO) is pushing for Universal Health Coverage (UHC) across many countries. It is a well-established fact now, that countries that invest in UHC make a sound investment in their human capital. In recent decades, UHC has emerged as a key strategy to make progress towards other health-related and broader development goals. Access to essential quality care and financial protection not only enhances people’s health and life expectancy, it also protects countries from epidemics, reduces poverty and the risk of hunger, creates jobs, drives economic growth and enhances gender equality.
Though India’s health indicators have made some improvements over the last decade, it is still lagging when compared to other countries similar to it in progress and per capita Gross Domestic Product (GDP). Indian Government expenditure on healthcare is a little over 1% of GDP today. In contrast, the world average healthcare outlay stands at 5.99%. Cross-country comparable NHA (National Health Accounts) data shows that India’s OOP (out of pocket) spending as a proportion of total health expenditure is extremely high when compared with BRICS nations. International experience indicates that low public spending is behind the high OOP share in India. Of the total health spending in India, the government contributes just 29%. Apart from financial neglect, the quality of public health services is another serious problem. The average middle-income Indian has shifted to private centres, thereby, increasing the average out-of-pocket health expenditures.
Owing to unreliable public health services and an unviable health insurance model, the poor are compelled to spend heavily on private medical care when faced with health shocks; this drives many people into the fold of poverty. It is well known that 85% of all healthcare needs can be managed effectively at the primary care level, where the costs of care are substantially lower (including curative, preventive, and promotive care). From the evidence across the world, it appears that the countries that have a strong primary healthcare system have better health outcomes, lower inequalities in these outcomes, and lower costs of care.
The current status of Primary Health Centres (PHC) in India is very grim. In the 25,650 PHCs in the country, 15,700 (61.2%) function with one doctor each. As many as 1,974 (7.69%) do not have even a single doctor. While 9,183 (35.8%) of the total number of PHCs do not have a lab technician, 4,744 (18.4%) do not have a pharmacist. Primary healthcare services in India are located too far from the populations they serve, provide too little services, and have too little resources. Each PHC in India is supposed to serve a population of 25-30,000 (as per global standards one PHC serves a population of about 2000-3000).
Primary healthcare services in India rely too heavily on the presence of doctors, despite having a shortage of doctors nationally. Since many doctors do not often live in the rural areas, especially in remote areas, the primary health centres become dysfunctional. There is no cadre of primary care providers in the country, unlike many Western countries, where general physicians and nurse clinicians are the certified primary care providers. The effectiveness of healthcare system is also affected by the ability of the community itself to participate in designing and implementing the delivery of services.
Thus, strengthening PHCs would be a major step towards achieving improved health indicators which would be imperative to ensure we are able to reap the benefits of the demographic dividends in the years to come.
The PHC forms the anchor around which entire health-care delivery system is organised and it’s high time India revamps it. Rights-based approach providing a ‘Right to Primary Healthcare’ can be the first step towards fixing India’s crumbling primary healthcare system. This can be a first step towards enhancing primary health facilities in both rural and urban areas. It is also recommended that the government systematically increase its health outlay to 2.5 % of GDP by 2025. The effectiveness of healthcare system is also affected by the ability of the community itself to participate in designing and implementing the delivery of services.
Thus, effectively engaging civil society to design and manage such delivery provides empowerment to the community as well as better access, accountability, and transparency.
The healthcare delivery must be made more consultative and inclusive. This can be achieved by employing methodologies based on community-based monitoring, which has worked successfully in many parts of the world. Finally, there is a need to introduce new and innovative ways of service delivery. The new model of service delivery should focus on expanded institutional capacity, as well as new courses and cadres, to overcome the shortages of skilled human resources in the healthcare system. Public Health Management cadres should be created in all states.
A variety of specialised nursing and paramedical courses should be introduced even as Accredited Social Health Activists (ASHAs) should be given the option to become auxiliary nurse midwives. In India, there is a shortage of high caliber senior staff in primary healthcare to act as trainers and role models. Developing the required cadre of primary healthcare doctors, nurses, and other staff will strengthen the support of hospital clinicians.
Finally, the power of technology to solve the last mile in primary healthcare is immense and given the scale of India’s healthcare deficit in primary care, this should be looked at with all the seriousness. Technology-based solutions to improve India’s primary healthcare will be faster, reliable and cheaper.
All put together, an approach that acknowledges the gravity and diversity of the situation and involves the community itself will be able to provide a lasting solution to India’s looming health crisis.
Sukanya Bhaumik is a Senior Programme Officer with the Public Affairs Centre, a not-for-profit think-tank based in Bengaluru.