Why states must get primary healthcare right

Published: December 3, 2018 2:51 AM

It will help poor and low-performing states improve health outcomes. PHC/CHC reform is as crucial as having health & wellness centres.

This would translate into reduction of costs at the secondary- and tertiary-care levels.

By Sarit Kumar Rout

The Union government’s policy push for developing health and wellness centres is a well thought out step for renewing focus on comprehensive primary care. The experiences of several countries show that investing in primary healthcare leads to allocative efficiency by bringing a range of preventive, curative, promotive and rehabilitative services closer to the people. Countries with greater primary care orientation have lower rate of mortality and better health outcomes. Developed countries including the UK, Canada, the Netherlands and Sweden that have substantially improved health outcomes, have given due priority to designing primary care to address their population’s needs and health problems. The UK allocates a large proportion of the overall budgeted expenditure to primary care. In India, despite several policy statements to improve primary care, this has never been a priority until recently, when the Union government announced the introduction health and wellness centre under its Ayushman Bharat programme, which will be the foundation for public health system in the country.

These centres are intended to provide outpatient care, immunisation, maternal and child health services, non-communicable diseases (NCDs) and other services. These centres will be linked to secondary and tertiary care and will be supplied with adequate drugs and diagnostic services. Once developed, these centres will help ameliorating basic health problems including early diagnosis and treatment of NCDs, avoiding complications in the latter stage and thereby, lessening costs of treatments. This would translate into reduction of costs at the secondary- and tertiary-care levels.

India’s progress towards achieving universal health coverage (UHC), though fraught with several constraints, can be quicker with a comprehensive primary-care approach as this provides healthcare to all irrespective of caste, income and religion, with higher coverage and at lower cost. Historically, India’s health systems bear the brunt of low public spending, causing the health systems to function sub-optimally and forcing millions of people to spend from their pocket at the point of care. However, Ayushman Bharat—a component of which intends to provide insurance coverage of `5 lakh to 500 million people—is envisaged to alleviate household out-of-pocket expenditure to a large extent. This, along with wellness centres—if designed and implemented properly—will provide ample impetus to achieve universal healthcare. This can contribute to realising India’s SDG commitments that aim to provide appropriate and high-quality healthcare to all with adequate financial protection.

The current approach, though admirable in many respects, requires re-emphasising the missing priority on PHCs and CHCs for developing comprehensive primary care. Focusing on health and wellness centres for improving primary care may fall short of achieving the desired target if there is no intention to invest in and restructure PHCs and CHCs. Achieving comprehensive primary care requires a paradigm shift from disease-control vertical programmes to community-led, people-oriented primary care. The resource-constrained and low-performing states—especially, Odisha, Bihar, Rajasthan and Uttar Pradesh—which are at the early phase of disease transition, may gain noticeably by going for comprehensive primary care.

Sharper focus in these resource-starved states should be on improving efficiency in spending without compromising equity, and this can be attained by designing programmes that would cover a large number of people and a wide range of diseases. Indian households incur higher out of pocket expenditure due to outpatient visits, and a comprehensive primary care with adequate and timely supply of drugs and appropriate diagnostic services can alleviate this significantly.

Moreover, it is relevant to develop low-cost primary care service delivery models involving nurses and allied health professionals which can lower the burden on the public health system—marked by the stress of a low doctor-strength. Several studies have pointed out that health systems heavily reliant on specialised care like the US are expensive as well as iniquitous because they forbid access to the vulnerable population. Hence, we need to design health services to meet local needs with apposite referral mechanism to secondary- and tertiary-care, and this can produce better health outcomes with a considerable cost-advantage. In this context, the role of public health professionals, those who can help design outreach and preventive programmes and implement the continuing health programme effectively, assumes paramount importance. We lack the required number of public health professionals. The shortage is severe in many parts of the country, especially poorer states like Odisha, Jharkhand, Chhattisgarh and Rajasthan. The focus should be to train a pool of social workers, psychiatrists, counsellors with public health orientation who could then transform the primary healthcare delivery system in the country.

Despite available evidence confirming the role of primary care in improving population health outcome with equity, our resource allocation is not geared towards it. Approximately, 51% of total government expenditure on health is spent on primary care; this needs to be stepped up to at least two-third of the government expenditure as suggested in the health policy document of India. A higher percentage of primary care expenditure is on personalised, curative care, leaving a paltry sum for population-based primary preventive care. Reorienting resources towards population-based preventive programmes will help set the allocation of scare resources for larger social benefits right. Since the states have higher responsibility than the Centre in matters related to health, the blueprints of primary care can further be redefined in view of the local needs. This should be the policy agenda for the low-performing and resource-constrained states.

Associate professor, Indian Institute of Public Health, Bhubaneswar, PHFI. Views are personal.

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