Inadequate prescription
The Niti Aayog’s proposal to strengthen secondary and tertiary health care services through public-private partnerships, keeping the under-served primary segment out of its ambit, will be counter-productive
The proposal of the Niti Aayog and the ministry of health and family welfare to strengthen secondary and tertiary health care with the resources of the private sector has not come a day too soon. However, not going the whole hog — by keeping primary health out — may end up as many of the typical “neither here nor there” solutions of yore.
There is an immutable and fundamental tenet in public health: A medically robust and economically sustainable health care delivery system prioritises intervention aimed at both preventing the onset of illnesses (services such as vaccination) and ensuring that simple illnesses don’t get serious. Primary and preventive health services are the silver bullets that make this possible. The proposal ignores this aspect. In this age of seamless connectivity and service delivery innovations that can remotely leverage private resources, the neglect is almost unconscionable. Wide availability of cell phones and recent Digital India initiatives promise unprecedented opportunity to create universal access.
Any fresh initiative in this field needs to have an unwavering focus on the services delivered at the 153,700 sub-centres and 25,300 primary health centres. They are designed to serve as the first point of entry, enabling the system to operate on a triaging basis. Since primary and preventive health together account for over three-fourths of the case load, the task for the authorities is to strengthen resources at these levels, which help providers determine whether they treat a medical condition on their own or refer to higher competencies. This filtering process becomes the foundational brick of the continuum of the care edifice.
The reluctance of the Niti Aayog to start from the bottom is understandable to an extent. No private doctor is willing to work in rural areas. Specialists and experienced GPs, who are necessary to provide tertiary and high-end secondary care, are in very short supply in the public sector (there is already a shortage of specialists of up to 70 per cent, and getting worse) and the private sector is happy to fill the void. But deploying doctors for secondary and tertiary health services without a strong foundation of primary care is counter-productive — many large studies released by the government itself show that currently over 70 per cent of the care at the tertiary and secondary levels is primary health. Now you know why there are three patients to a bed or not an inch of space on the floor in sadar hospitals!
Considering that private doctors barely exist in rural India, the strategy therefore requires better management of the measly 27,400 doctors deployed in the primary health centres for a rural population of 900 million (a ratio of one doctor per 33,000 versus the required one per 1,000) and supplementing them with doctors in the private sector, either by deploying them at the PHCs — not easy — or through teleconsulting systems that leverage doctors in urban areas. Since bridging the shortfall through physical deployment is well-nigh impossible despite 45,000 doctors graduating every year, use of the rapidly expanding telecom network is the next best alternative.
Primary and preventive services are essentially simple. They need basic skills and frugal facilities which make them totally amenable to a digital system connecting with a distant doctor. In fact, the Indian expertise in data compression has already made it possible for medical diagnosis, supported by remotely obtained vital parameters such as blood pressure, sugar, foetal sounds, cardiac signals (and many more), to be delivered even in a universal 2G environment. The Union Cabinet’s decision on July 19 to strengthen rural broadband with the infusion of ~42,000 crore to reach 2.5 lakh panchayats by March 2019 will improve matters further and augurs well for expanding the range of services through technology-based solutions. Projections released by the department of telecommunication on October 26 show that one lakh panchayats will be covered by fibre optic links by the end of this year. This is impressive progress and augurs well for the future.
Teleconsultations will also address a major drawback of current public-private partnerships — the inability to independently monitor delivery of services, often leading to allegations of fudging. A digital system stores all consultations and prescriptions on a server, thereby strengthening the ability to centrally monitor all aspects of the consultation in real time or offline.
The Niti Aayog also needs to understand the psychographics of the consumer in healthcare delivery. The poorest of rural families will somehow raise resources and travel long distances if a family member needs tertiary or secondary services, because the illness is usually serious and life-threatening. But for primary and preventive health, the same family will expect the services to be available outside its doorstep, failing which they will not show up despite the need. It is time we accept this reality and find solutions around this.
While the Niti Aayog can bring private providers to expand services at district hospitals, private participation in primary health can provide the way for utilising unspent amounts such as the ~9,500 crore for reproductive and child health of the National Rural Health Mission, as pointed out in the report of the Comptroller and Auditor General tabled in Parliament three months ago. The services covered under the RCH programme would have been almost totally primary health.
It is also time technology is used more creatively with the current resources. A number of states have adopted technology solutions at the service delivery level which, however, are focused on indicators and metrics to address the needs of administrators. This creates additional burden for lower-level staff, since the data input is an independent activity to be done manually. It is no surprise it has rarely worked well. The starting point needs to be on giving management tools that help the ANMs and doctors conduct their current tasks more easily in which metrics for management emerge as the automatic by-product of service delivery.
Since private doctors barely exist in rural India, teleconsulting systems that use the services of urban doctors are the next best alternative