Topic: Capacity building for Primary Health Care
Topic in Syllabus: GS Paper 1 : Social Issues
- There is scarcity of MBBS trained primary care physicians.
- The National ratio is 0.76 per 1,000 population and it is one of the lowest in the world.
- Moreover, they are not willing to serve in rural / remote areas.
- Urban-rural disparities in physician availability is increasing the burden of chronic diseases.
- It is making the health care in India, both inequitable and expensive.
Primary healthcare (PHC):
- Primary healthcare (PHC) refers to “essential health care” that is based on “scientifically sound and socially acceptable methods and technology, which make universal health care accessible to all individuals and families in a community.
- It is through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.
- PHC is an approach to health beyond the traditional health care system that focuses on health equity-producing social policy.
- PHC includes all areas that play a role in health, such as access to health services, environment and lifestyle thus, primary healthcare and public health measures.
Goals and principles:
The ultimate goal of primary healthcare is the attainment of better health services for all. It is for this reason that World Health Organization (WHO), has identified five key elements to achieving this goal.
- reducing exclusion and social disparities in health (universal coverage reforms);
- organizing health services around people’s needs and expectations (service delivery reforms);
- integrating health into all sectors (public policy reforms);
- pursuing collaborative models of policy dialogue (leadership reforms)
- Increasing stakeholder participation.
Primary Health Centre (India):
Primary Health Centre (PHCs), sometimes referred to as public health centres, are state-owned rural health care facilities in India. They are essentially single-physician clinics usually with facilities for minor surgeries, too. They are part of the government-funded public health system in India and are the most basic units of this system.
Apart from the regular medical treatments, PHCs in India have some special focuses:
- Infant immunization programs: Immunization for newborns under the national immunization program is dispensed through the PHCs. This program is fully subsidized
- Anti-epidemic programs: The PHCs act as the primary epidemic diagnostic and control centres for the rural India. Whenever a local epidemic breaks out, the system’s doctors are trained for diagnosis. They identify suspected cases and refer for further treatment.
- Birth control programs: Services under the national birth control programs are dispensed through the PHCs. Sterilization surgeries such as vasectomy and tubectomy are done here. These services, too, are fully subsidized.
- Pregnancy and related care: A major focus of the PHC system is medical care for pregnancy and child birth in rural India. This is because people from rural India resist approaching doctors for pregnancy care which increases neonatal death. Hence, pregnancy care is a major focus area for the PHCs.
- Emergencies: All the PHCs store drugs for medical emergencies which could be expected in rural areas. For example antivenoms for snake bites, rabies vaccinations, etc.
Challenges in Primary Care:
Primary care is an important part of the healthcare system that helps to reduce complications and hospital admissions through prevention and early intervention. However, there are a number of challenges that are facing primary care that must be addressed to maintain the quality and benefits that primary care can provide. These challenges include, but are not limited to lack of choice, variable quality, reactive versus proactive decisions and physician shortages.
Lack of Choice:
- Each general practitioner has a particular way of working with patients and promoting their health, which is more compatible with some patients than others. For this reason, it is important that patients are in a position to make a selection and find the general practitioner that best caters to their needs.
- However, in some regions there is a noticeable lack of choice and patients may not receive all the benefits of primary care, as they do not have access to the physician best suited to their needs.
- The quality of primary care varies considerably between different practitioners and regions. This can be an issue in some areas where the level of primary care is lacking, and patients may not receive the full benefits. Additionally, different models and types of primary care practices, including public and private based models, highlight the disparity to a greater extent.
- There are currently few mechanisms in place to promote higher quality practice such as peer reviewing, performance-based incentives or risk of losing their contract in severe circumstances. It has been suggested that implementing some of these systems may help to improve the quality of care.
Reactive vs. Proactive Decisions:
- One of the main aims of primary care is for patients to have a trusted practitioner to talk about any symptoms or health issues before they become significant issues that require advanced treatment with risks.
- However, many of the management decisions remain reactive rather than proactive, and some complications could be avoided if proactive decision-making was more widespread. There are currently incentives being implemented in many countries to promote earlier management of some health conditions
- In order to meet the primary health care demands of the public, there must be an adequate supply of physicians to provide quality care. This is a significant challenge as the health demands are currently increasing more rapidly than the physician supply.
- To manage this issue, several approaches will need to be combined. This may include increasing the number of physicians that are trained, improving workplace systems and increasing the efficiency of care without compromising the quality.
Neglect of Rural Population:
- A serious drawback of India’s health service is the neglect of rural masses. It is largely a service based on urban hospitals. Although, there are large no. of PHC’s and rural hospitals yet the urban bias is visible. According to health information 31.5% of hospitals and 16% hospital beds are situated in rural areas where 75% of total population resides.
- Moreover the doctors are unwilling to serve in rural areas. Instead of evolving a health system dependent on paramedical (like bare-footed doctors in China) to strengthen the periphery. India has evolved one dependent on doctors giving it a top-heavy character
Emphasis on Culture Method:
- The health system of India depends almost on imported western models. It has no roots in the culture and tradition of the people. It is mostly service based on urban hospitals. This has been at the cost of providing comprehensive primary health care to all. Otherwise speaking, it has completely neglected preventive, pro-motive, rehabilitative and public health measures.
- The growth of health facilities has been highly imbalanced in India. Rural, hilly and remote areas of the country are under served while in urban areas and cities, health facility is well developed. The SC/ST and the poor people are far away from modern health service
Expensive Health Service:
- In India, health services especially allopathic are quite expensive. It hits hard the common man. Prices of various essential drugs have gone up. Therefore more emphasis should be given to the alternative systems of medicine. Ayurveda, Unani and Homeopathy systems are less costly and will serve the common man in better way. Concluding the health system has many problems. These problems can be overcome by effective planning and allocating more funds.
Government measures for capacity building in Primary health care:
National Health Policy, 2017:
The National Health Policy 2017 recognizes that improved access, education and empowerment would be the basis of successful population stabilization. The policy imperative is to move away from camp based services with all its attendant problems of quality, safety and dignity of women, to a situation where these services are available on any day of the week or at least on a fixed day.
- Assurance Based Approach- Policy advocates progressively incremental Assurance based Approach with focus on preventive and promotive healthcare
- Health Card linked to health facilities– Policy recommends linking the health card to primary care facility for a defined package of services anywhere in the country.
- Patient Centric Approach- Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices. Standard Regulatory framework for laboratories and imaging centers, specialized emerging services, etc
- Micronutrient Deficiency– Focus on reducing micronutrient malnourishment and systematic approach to address heterogeneity in micronutrient adequacy across regions.
- Quality of Care– Public hospitals and facilities would undergo periodic measurements and certification of level of quality. Focus on Standard Regulatory Framework to eliminate risks of inappropriate care by maintaining adequate standards of diagnosis and treatment.
- Make in India Initiative- Policy advocates the need to incentivize local manufacturing to provide customized indigenous products for Indian population in the long run.
- Application of Digital Health- Policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience.
- Private Sector engagement for strategic purchase for critical gap filling and for achievement of health goals.
The National Medical Commission Bill, 2017:
A contentious element of the National Medical Commission (NMC) Bill 2017 an attempt to revamp the medical education system in India to ensure an adequate supply of quality medical professionals has been Section 49, Subsection 4 that proposes a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine. This sitting, referred to in Subsection 1, may “decide on approving specific bridge course that may be introduced for the practitioners of Homoeopathy and of Indian Systems of Medicine to enable them to prescribe such modern medicines at such level as may be prescribed.
Key features of the Bill include:
- The Bill seeks to repeal the Indian Medical Council Act, 1956 and provide for a medical education system which ensures:
- availability of adequate and high quality medical professionals
- adoption of the latest medical research by medical professionals
- periodic assessment of medical institutions
- An effective grievance redressal mechanism.
- Constitution of the National Medical Commission:
- The Bill sets up the National Medical Commission (NMC). Within three years of the passage of the Bill, state governments will establish State Medical Councils at the state level.
- A Search Committee will recommend names to the central government for the post of Chairperson, and the part time members. These posts will have a maximum term of four years. The Search Committee will consist of seven members including the Cabinet Secretary and three experts nominated by the central government (of which two will have experience in the medical field).
- Functions of the National Medical Commission: Functions of the NMC include:
- framing policies for regulating medical institutions and medical professionals,
- assessing the requirements of healthcare related human resources and infrastructure,
- ensuring compliance by the State Medical Councils of the regulations made under the Bill,
- Framing guidelines for determination of fees for up to 40% of the seats in the private medical institutions and deemed universities which are regulated as per the Bill.
- Entrance examinations:
- There will be a uniform National Eligibility-cum-Entrance Test for admission to under-graduate medical education in all medical institutions regulated by the Bill. The NMC will specify the manner of conducting common counselling for admission in all such medical institutions.
- There will be a National Licentiate Examination for the students graduating from medical institutions to obtain the license for practice. The National Licentiate Examination will also serve as the basis for admission into post-graduate courses at medical institutions.
- AYUSH is the acronym of the medical systems that are being practiced in India such as Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy.
- These systems are based on definite medical philosophies and represent a way of healthy living with established concepts on prevention of diseases and promotion of health.
- The basic approach of all these systems on health, disease and treatment are holistic.
- Because of this, there is a resurgence of interest on AYUSH systems. Yoga has now become the icon of global health and many countries have started integrating it in their health care delivery system.
- The Department of Indian Medicine and Homeopathy (ISM & H) was created in the Union Ministry of Health and Family Welfare. In 2003, this Department was re named as Department of AYUSH.
Benefits of AYUSH system are:
- It addresses gaps in health services.
- It provides low cost services in far-flung areas.
- AYUSH can provide best care to elderly.
- Problem of tobacco and drug abuse can be tackled by AYUSH especially through Yoga.
- Useful in lifestyle diseases like diabetes and hypertension.
- Large part of the population prefers AYUSH as it is perceived to have lower side effects, costs and considerations of it being more natural.
Challenges in the AYUSH system:
- The ability of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners to cross-practice to highlighting current restrictions on allopathic practitioners from practicing higher levels of caregiving. However, these debates miss the reality: which is a primary health system that is struggling with a below-par national physician-patient ratio (0.76 per 1,000 population, amongst the lowest in the world) due to a paucity of MBBS-trained primary-care physicians and the unwillingness of existing MBBS-trained physicians to serve remote/rural populations. Urban-rural disparities in physician availability in the face of an increasing burden of chronic diseases make health care in India both inequitable and expensive.
- Quality standards of Medicines – Scientific validation of AYUSH has not progressed in spite of dedicated expenditure in past.
- Lack of human resources – Practitioners are moving away from traditional system for better opportunities
- The existing infrastructure remains under-utilized.
- The 4th Common Review Mission Report 2010 of the National Health Mission reports the utilisation of AYUSH physicians as medical officers in primary health centres (PHCs) in Assam, Chhattisgarh, Maharashtra, Madhya Pradesh and Uttarakhand as a human resource rationalization strategy. In some cases, it was noted that while the supply of AYUSH physicians was high, a lack of appropriate training in allopathic drug dispensation was a deterrent to their utilization in primary-care settings.
- The 2013 Shailaja Chandra report on the status of Indian medicine and folk healing, commissioned by the Ministry of Health and Family Welfare, noted several instances in States where National Rural Health Mission-recruited AYUSH physicians were the sole care providers in PHCs and called for the appropriate skilling of this cadre to meet the demand for acute and emergency care at the primary level.
The way forward for capacity building in the AYUSH system:
- Capacity-building of licensed AYUSH practitioners through bridge training to meet India’s primary care needs is only one of the multi-pronged efforts required to meet the objective of achieving universal health coverage set out in NHP 2017.
- There is an urgent need for a trained cadre to provide accessible primary-care services that cover minor ailments, health promotion services, risk screening for early disease detection and appropriate referral linkages, and ensure that people receive care at a community level when they need it.
- The issue of AYUSH cross-prescription has been a part of public health and policy discourse for over a decade, with the National Health Policy (NHP) 2017 calling for multi-dimensional mainstreaming of AYUSH physicians. There were 7.7 lakh registered AYUSH practitioners in 2016, according to National Health Profile 2017 data. Their current academic training also includes a conventional biomedical syllabus covering anatomy, physiology, pathology and biochemistry. Efforts to gather evidence on the capacity of licensed and bridge-trained AYUSH physicians to function as primary-care physicians have been under way in diverse field settings, and the call for a structured, capacity-building mechanism is merely the next logical step.
- Current capacity-building efforts include other non-MBBS personnel such as nurses, auxiliary nurse midwives and rural medical assistants, thereby creating a cadre of mid-level service providers as anchors for the provision of comprehensive primary-care services at the proposed health and wellness centres.
- the existing practice of using AYUSH physicians as medical officers in guideline-based national health programmes, a location-specific availability of this cadre to ensure uninterrupted care provision in certain resource-limited settings, as well as their current academic training that has primed them for cross-disciplinary learning hold promise.
- These provide a sufficient basis to explore the proposal of bridging their training to “enable them to prescribe such modern medicines at such level as may be prescribed”.
- Ensuing discussions will be well served to focus on substantive aspects of this solution: design and scope of the programme, implementation, monitoring and audit mechanisms, technology support, and the legal and regulatory framework. In the long run, a pluralistic and integrated medical system for India remains a solution worth exploring for both effective primary-care delivery and prevention of chronic and infectious diseases.
Critically evaluate the Indian primary health care system? And discuss the initiatives taken by the government to empower primary health care.