Primary Heath Care

Arjun Mehta

Kanika Vyas

Neha Saini

Rohan Wahane

Tarun Arora 1

IIM Lucknow

Executive Summary

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Facts related to health care

Problems faced by India

Approach taken

Key highlights and solutions

Vision 2025

Flow of the presentation

India has some of the best tertiary care in the world and is gradually acquiring a name for itself even in the field of 'medical

tourism'. Secondary care is still a significant challenge, but even in several smaller towns and district headquarters, there is a

growing supply of maternity homes and multi-speciality secondary care facilities. In all of these systems, primary care forms

the anchor around which the entire system is built and there is a high level of integration between various levels of care with

strong gate-keeping and patient management functions being performed by the primary healthcare providers. The actual

situation in this regard on the ground in India is very grim. In most parts of the country, formal primary care is virtually non-

existent. Within the urban context, there is a some amount of formal primary care available in the form of general

practitioners, ophthalmologists, dentists, etc. We have identified operational issues in the system and provided a solution that

how partnerships can improve the face of primary system in India.

Where does India stand ?

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21% Global disease burden and largest communicable disease burden with India

3rd Highest among countries with high rate of HIV-infected persons

33% Lack access to proper sanitation

3.3 per 10,000 Doctors in rural areas as compared to 13.3 per 10,000 in urban areas

• Grossly underfunded, under staffed, and poorly equipped

• Allopathic physicians highly concentrated in urban areas

• Similar trends in concentration of nurses and midwives

Public Health Infrastructure

• Both urban and rural Indian households tend to use private medical sector more frequently than public sector

• Due to poor level of quality care in public sector

• Long wait lines, inconvenient hours of operation and distance of public sector facility

Private Health Care

• Public spending on health care in India as low as 0.9% of GDP in contrast to total health expenditure of 5% of GDP

• Decreasing public health expenditure has adversely affected the health outcomes

Health Care Costs

• Only 25% of rural population has availability to piped water as compared to 75% in urban areas

• Only 20% of total hospital beds in rural areas which have 68% of India’s population

• Infant mortality rate in poorest 20% 2.5 times higher than the richest 20%

Urban Rural Disparities

Communicable diseases have a major impact on the decrease in lives of people. Majorly due to unawareness, carelessness and not taking enough precautions.

The nurses ratio to population which stands at current 0.1% is very less and needs improvements.

Major reason for maximum infant death is non availability of medicines at the right time.

We need to work on improving current levels of sanitation and water cleanliness in order to establish intrusive development

Private Infrastructure has improved but we are delivering half of what is a global average and not even close to WHO guidelines

WHO survey ranks India 171 out of 175, in terms of total GDP spent on healthcare. Nepal, Bangladesh are better than India. Also the utilization percentage of the budget is not 100%

Key Issues and Ground Realities

Inadequate human resources to staff primary care, evidenced by

limited ability to recruit and retain high quality staff,

particularly in disadvantaged areas

Failure to deliver universally the key primary care services

necessary to reach MDG targets (vaccination, nutrition and

hygiene support, safe maternity services, effective first contact acute care for serious disease)

Failure to deliver effectively the primary care services which reduce health system costs

(prevention and care of chronic diseases, effective diagnosis and

prioritization for hospital referral)

Lack of public and clinical governance of performance

Poor leadership, public regard, and professional status

Problems Identified

Overall generic problems

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Underlying operational problems

Funding Models 1

• Funding models that are unresponsive to the value of high quality acute, preventive, and chronic care outside hospital

Distribution and Financing Schemes 2

• Distribution and financing mechanisms for medicines that do not take advantage of the availability of effective generic medicines

Information Systems 3

• Lack of effective information systems, including failure to exploit the opportunities for patient involvement in self care inherent in modern information technology

Human Resources 4

• Multiskilling i.e. training individuals to perform tasks within their capacity but beyond their traditional professional roles which will allow the available workforce in the team to be deployed most efficiently

Problem Summary

• Primary care is an extremely unattractive career for allopathic doctors

• Virtually no community based postgraduate training and poor career prospects

• 10% of posts for doctors at the PHCs and 63% of the specialist posts at the CHCs, and 25% of the nursing posts at PHCs and CHCs combined remained unfilled

• 27% of pharmacist and 50% of laboratory technician posts also vacant

Human Resources

Platforms to build on

•Training and professional support for nurses and other staff in primary care teams

•Develop enhanced specialist roles by partnership between professional bodies, Universities, and private educational providers

•Specific areas of reported need which could be met include emergency medicine, child health, orthopedics

•Tie up with countries of special repute in Health Care in training and implementation development

•Disciplines that need support in delivering enhanced skills training include physiotherapists, dieticians, paramedics and therapists

Strategic Points

• Introduce incentive schemes—monetary and non-monetary—and compulsory service bonds to enhance recruitment of good doctors to rural areas

• Establish partnership with international colleges of repute for nurse training

• Establish new nurse institutes on the lines of ITI across India. Award special economic and infrastructure status to these institutes

• Preference for admission to education and training courses for doctors and to local students from rural and underserved areas

• Preference to clinical workers of local areas for postgraduate training, financial incentives, communication facilities, and opportunities for education of their children

• Reintroduce compulsory service in underserved areas by all medical graduates

Problem Summary

• Major difference in MDG health indicators between urban and rural areas and between states

• India is also off- track to meeting its declared national and MDG targets for child mortality

• Projected infant mortality rate between states varies 12-fold, from 5/1000 in Goa to 58/1000 in Madhya Pradesh and Meghalaya

• Failure to vaccinate and treat the common childhood infections effectively

• Poor supply and distribution of vaccines, including cold chain failures, are reported to be common despite India being a major vaccine producer

Universal Services

Platforms to build on

• Technical advisory teams (TASTs) for provision of expert support from multi nation and Indian expertise

• Development of local capacity and sustainability

• Use of modern technology for early recognition of the acutely ill child in community settings both in measuring vital signs and by parent involvement

• Can be at a system (help line numbers) or an individual level (using mobile) as a means of communication with the parent or for distance monitoring system

• Strong potential for R&D partnership with the IT and health technology sector in India to develop innovative affordable technologies with very wide scale application

Strategic Points

• Build on innovative and effective community development activities

• Employ social health activists and auxiliary midwives, establishing local sanitation committees, and organize emergency transport systems

• Innovative approaches to obstetric care that have reduced maternal mortality by building effective local teams integrating primary and hospital care

• Ensure that women have access to high quality antenatal care as well as increasing the number of births taking place in a safe environment

Problem Summary

• Chronic diseases (such as heart disease, diabetes)are the leading cause of death and disability in India.

• Care currently provided by the private sector and is expensive.

• A substantial proportion of the population receive no treatment (47% of diabetics and 91% of those with angina)

• Restricted availability of preventive care, particularly in poor and rural populations, increasing the burden of disease.

• Detection of chronic at later stage due to lack of systematic screening

• The lack of a strong primary care function also means that diagnostic triage for both acute and chronic disease is usually conducted by hospital based doctors.

• high levels of investigation

• use of more expensive non-generic medicines

• potential for inappropriate management by someone working outside their area of specialist expertise.

• Unavailability of cost effective generic in primary care; nor are they routinely used when they are available.

Strengthening capacity to deliver services which reduce system cost

Strategic Points

• India has a major advantage in dealing with its epidemic of chronic disease because its generic pharmaceutical companies produce high quality medicines at cheapest prices in the world.

• Effectiveness of Health workers at managing chronic mental health problems (both anxiety & depression)

• Effectiveness of the diagnostic triage function with access to standard diagnostic facilities like blood tests, ultrasound, and imaging.

• Effectiveness of technology assisted self care (self-monitoring of blood pressure, blood glucose) in reducing morbidity and mortality.

• Self-management of chronic illness also reduces healthcare workload and costs essential diagnostic and monitoring technologies

• Affordable cost

• Allow real time monitoring or screening for a range of other chronic diseases like diabetes

Platforms to build on

•Primary care doctors making referral decisions on the basis of accurate diagnoses and managing most patients in the community according to evidence based guidelines using generic drugs

•Creating PPP initiatives and developing innovative care pathways for chronic care and achieving a level of staff motivation

•Facilitating the use of computerized medical records and patient management systems for chronic disease prevention and management

•Developing a cadre of primary care based advanced nurses specializing in chronic diseases as well as nurses and healthcare workers working at less specialized levels

•Benefit : Provides a career framework for health workers to become advanced nurse specialists

•Starting at the level of the ASHA worker and ending with an advanced nurse practitioner.

Problem Summary

• Major variations between states in the efficacy of governance.

• Limited knowledge in local governance

• Outcome of care not being monitored effectively.

• Poor quality services, wastage, corruption. weak management characterise primary healthcare institutions.

• Problem of ‘ghost workers’ with up to a 50% absentee rate

• Huge unexplained variation in both within and between states.

• public and private sectors

• differently qualified practitioners in drug prescribing and frequency of surgical interventions

• Inadequacy of training and attitudes to deliver care of a consistently good standard.

Strengthening public and clinical governance

Platforms to build on

•Building effective internal investigation and inquiry to track poor governance in the health services and documenting them.

•Karnataka, have already instituted strong governance programmes based on community involvement and decentralised planning leading to improvements in health outcomes.

•Andhra Pradesh has established health financing schemes (to improve the access of below poverty line families to secondary and tertiary care) which are built on IT platforms aimed at ensuring clinical, financial, and administrative governance. Such systems could potentially be extended into primary care.

• Taking a cue from the corporates and starting an appraisal system on performance basis for each primary care clinician based on quality outcome standards and patient feedback

Strategic Points

•Remuneration for primary care to be based on assessment of performance against evidence based on nationally agreed quality standards. Adherence to these standards is assessed by central electronic interrogation of computerised patient records.

•All clinical activity undertaken in primary care facilities, including prescribing and recording of medical records, should be electronic & linked with financial management system.

•At district level all financial and clinical performance of all primary care centres to be overseen by NRHM

•Creating a network of primary care providers to develop a demand led situation—giving patients choice to register with the right primary care provider

•Conducting a nationally annual survey to evaluate consumer satisfaction with primary recording patient views about service quality and ease of access.

•Creating IT support for clinical decisions by doctors and self-care by patients to improve care quality and clinical governance.

Problem Summary

• Primary care is not yet recognized by the Medical Council of India (MCI) as a specialty

• Primary care practitioners therefore have no formal postgraduate training, no specialist accreditation, and no system for career progression

• They have lower pay and worse working conditions than their hospital colleagues

• Lack of appropriate training or qualification does not at present appear to be a barrier to employment as a primary care doctor

• The current primary care structure requires recruitment of doctors to posts in rural areas where basic housing and education along with facilities for personal healthcare may be poor

• Failure to recruit quality practitioners to primary care over many years means that there is no pool of well trained and motivated primary care practitioners to act as leaders and university faculty and train the next generation

Primary Care Leadership

Platforms to build on

• The professional regulatory councils in India can do much to support the development of primary care.

• Great potential to share knowledge and expertise with international counterparts on how to promote the training and recognition of primary care practitioners.

• Links between nursing faculties are limited. There is an opportunity to remedy this and provide greater support for the efforts of Indian medical and nursing colleges to establish academic departments of primary care

• Partnership in establishing national/state conferences on primary care as a regular tradition

• Provide leadership training for primary care clinicians in India by partnering with international Primary Health Care organizations

Strategic Points

• The high quality diagnostic and curative primary care offered by doctors working in major hospital outpatients and polyclinics is limited in scope and function

• But possible starting point with greater capacity to develop effective clinical services working to international quality standards

• Recently established family practice models may evolve into a cohort of high quality community based primary care centers that could support training

• Harness public support to strengthen health literacy among the public and refine people’s expectations so that they begin to understand the risks of overmedication and over investigation

Primary Healthcare : India vs. Brazil

Key takers from Brazil (2010 vs. 1965)

• Health Insurance reach – 100%

• Doctor density: 1.7 per 1000– 425% rise

• Public expenditure: 4.2% - 200% rise

• Infant Mortality – 15 per 1000 births (Global : 38)

Transforming Health System : Political leadership -> Major Role

Creating universal access: Primary Focus, Secondary focus on efficiency or quality

High allocation from Primary Healthcare in Union Budget

Government should choose between payer or provider role

Decentralized Federal System supported by common policy framework

Key learnings from Brazil

Envisioning India 2025

Improved Financial Access

•Extensive Insurance cover which should move up from current 25% to 75%

•Those who cannot pay for healthcare would receive it for free under public provision

•Authentication and record setup done through the UID card

HealthCare resource Gaps

•Healthcare must be include under infrastructure industry

•Overall Bed density should reach 2.5 per 1000 (current: 1.3/1000)

•1.5 beds per rural areas and 3.8 beds in urban areas(current 0.3/1000 & 3.4/1000)

Workforce Improvement

•Upto 90% registered practioners must be working effectively

•AYUSH & Rural Medical Practioners need to be incorporated into mainstream healthcare at national level

•Doctor density should increase to 0.9/1000 with doctor to nurse ration maintained at 1:2

More Budgetary Allocation

• At least 5.5% of Annual Budgetary expenditure must be allocated to Primary Healthcare with focus on sanitation and clean drinking water

Integration of health facilities

• Public-private partnership and tracking of patient treatments

Generic Medicines

• Decrease on export of generic medicines and more effective utilization in the current Indian Setup

• Increase in awareness among rural and urban areas regarding generics

• Improvement in Generics Distribution across the nation

Vision 2025

• Glossary • ASHA :(Accredited Social Health Activist) • WHO – World Health Organisation

• References • Central Bureau of Health Intelligence in health sector, 2005&2010 • World Bank database • WDI • WHO • Global Health Expenditure Database • 12th 5year plan • http://indiabudget.nic.in • Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing healthcare for all: challenges

and opportunities. Lancet 2011;377:668-79. • Patel V, Kumar AK, Paul VK, Rao KD, Reddy KS. Universal health care in India: the time is right. Lancet

2011;377:448-9 • Rao M, Rao KD, Kumar AK, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98. • Sudarshan H, Prashanth NS. Good governance in health care: the Karnataka experience. Lancet 2011;377:790-2. • Vision 2015. Medical Council of India. March 2011. www.mciindia.org/tools/announcement/MCI_booklet.pdf. • Sundararaman T, Gupta G. Indian approaches to retaining skilled health workers in rural areas. Bull World Health

Organ 2011;89:73-7

Appendix and References

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