Healthcare in India is ailing. Here is how to fix it
Context:
The lesson emerging most unequivocally from the pandemic experience is that if India does not want a repeat of the immeasurable suffering and the social and economic loss, we need to make public health a central focus. The virus is still around. We have no option but to live with that reality.
Need of reforming public health sector
• The importance of public health has been known for decades with every expert committee underscoring it.
• Ideas ranged from instituting a central public health management cadre like the IAS, to assess, manage and control public health problems to adopting an institutionalised approach to diverse public health concerns — from healthy cities, enforcing road safety to immunising newborns, treating infectious diseases and promoting wellness.
• The process of reform to create a public health-centred primary healthcare system needs to start with looking evidence in the eye.
• Covid has also shifted the policy dialogue from health budgets and medical colleges towards much-needed and badly-delayed institutional reform. It is heartening to note that the Ministry of Health has issued guidelines to states to establish a public health cadre.
National Health Mission (NHM)
• The National Health Mission (NHM) seeks to provide universal access to equitable, affordable and quality health care which is accountable, at the same time responsive, to the needs of the people, reduction of child and maternal deaths as well as population stabilization, gender and demographic balance.
• The Framework for Implementation of NUHM has been approved by the Cabinet on May 1, 2013.
• NHM encompasses two Sub-Missions, National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
• The National Rural Health Mission (NRHM) was launched in 2005 with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country.
Issues with National Health Mission
• After 15 years of the National Health Mission (MHM), less than 10 per cent of the health facilities below the district level can attain the grossly minimal Indian public health standards.
• Clearly, the three-tier model of subcentres with paramedics, primary health centres with MBBS doctors and community health centres (CHC) with four to six specialists has failed primarily because of absence of an accountability framework.
• The facilities are designed to be passive — treating those seeking care.
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Suggestions
• Like Brazil, we need Family Health Teams (FHT) accountable for the health and wellbeing of a dedicated population, say 2,000 families. The FHTs must consist of a doctor with a diploma in family medicine and a dozen trained personnel to reflect the skill base required for the 12 guaranteed services under the Ayushman Bharat scheme — midwives, public health nurses, other paramedics, health workers and community workers.
• A baseline survey of these families will provide information about those needing attention.
• A team that ensures a continuum of care by taking the family as a unit and ensuring its well-being over a period.
o Nudging these families to adopt lifestyle changes, following up on referrals for medical interventions and post-operative care through home visits for nursing and physiotherapy services would be their mandate.
o Their work should be closely monitored and the personnel should be given outcome-linked monetary and non-monetary incentives.
• Such a system of primary care will need to work under the close supervision of a CHC manned by specialists in family medicine. If trained well and competently, they can handle most ailments and conditions that could and should be handled at the CHC level, referring only that needing specialist care.
• Creating appropriate cadres: There must be a public health cadre manning the posts at the PHC and CHCs consisting of sub-specialists in family medicine, public health and public health management.
o Likewise, among nurses, the cadre should comprise two distinct sets of personnel — public health nurses (not ANMs promoted based on seniority) and nurse midwives capable of independently doing all clinical functions for handling pregnancies and women’s health issues except surgical interventions.
• New skills, drastically upgraded competencies and a new mindset should be embedded within the vision of a patient, family and community-centred health system for Primary care in India to get traction.
• There is also a need to declutter policy dialogue and provide clarity to the nomenclatures.
• India needs to move beyond the doctor-led system and paramedicalise several functions.
• Instead of “wasting” gynaecologists in CHCs, when there is an overall shortage of them, midwives (nurses with a BSc degree and two years of training in midwifery) can provide equally good services except surgical, and can be positioned in all CHCs and PHCs.
o This will help reduce C Sections, maternal and infant mortality and out of pocket expenses.
• Laying counsellors for mental health, physiotherapists and public health nurses are critically required for addressing the multiple needs of primary health care at the family and community levels.
• Spending on pre-service and in-service training needs to be increased from the current level.
• A comprehensive redefinition of functions of all personnel is required to weed out redundancies and redeploy the rewired ones.