Integrated Care Networks – A HLEG Recommendation

By Zeena Johar, President, ICTPH

The High Level Expert Group (HLEG) on Universal Health Coverage (UHC) constituted by the Planning Commission of India was mandated towards developing a framework for providing easily accessible and affordable health care to all Indians. With financial protection as the primary objective UHC also required the availability of adequate healthcare infrastructure, skilled health workforce, and access to affordable drugs and technologies to ensure the entitled level and quality of care to every citizen.

Dr. Manmohan Singh, our Prime Minister declared in his Independence Day Address on August 15, 2011, that health would be accorded the highest priority in the 12th Five Year Plan which would become operational in 2012, clearly articulating governmental intent to increase the public financing of health to 2.5% of India’s GDP, during the course of the 12th Plan.

Universal Health Coverage (UHC), as defined by the HLEG panel of experts is defined as delivery to all persons of a package of services at the primary, secondary and tertiary levels. The HLEG report provides a detailed design and implementation framework for the UHC system.

The proposed increase in public spending will mostly be routed towards establishing primary healthcare systems. The conditional central assistance to states will ensure aligned incentives as they begin to implement the ‘change’. The mostly unorganized primary healthcare sector as of today, calls for a radical architectural transformation to achieve the goals set by UHC.

In our attempt to delivery universal health care, we primarily have three paths to follow (a) direct public provisioning at all levels (b) insurance led fee-for-service mechanisms; (c) capitation fee based contracting-in of private healthcare providers.

The HLEG report strongly supports, establishing ‘integrated care networks’, wherein the government would contract-in both public and private providers of healthcare at all levels. Multiple health systems across the world have adopted this methodology to provide their citizens access to universal health care, most notable the National Health Service (NHS) in the UK.

Establishing such care networks will bring the onus of appropriate referral on the defined first-point of contact, which will be the registered primary healthcare provider. ‘Gate-keeping’ as this is be defined in functional managed care set-ups globally, most notable the Kaiser Permanente network in the US.

Financing UHC providers based on number of registered members in the allocated population, and establishing methodologies such as ‘no registration denial’ will ensure that providers are not selective to enrol only the healthy inhabitants. Such an obligatory and no denial environment have ensured universal health coverage through private health insurance driven systems, most notably in Switzerland. Incentive mechanisms for UHC providers based on quality of care and population level health outcomes monitored through federal regulation and community based organization, will ensure no care denial and cost containment.

Costing a publically financed, capitation fee based healthcare delivery system calls for careful experimentation before national implementation. Models based on current expenditure levels will underestimate cost, as it will sideline the latent demand as the financial barrier to access will be resolved on launching UHC. Probalistic estimates accounting for the above mentioned features, driven by on-ground care-network delivery experiments will help evolve a model for national adoption.

Having outlined a framework for universal healthcare delivery, and the proposed pathway it becomes even more essential to consolidate models that have managed to demonstrate care delivery not only at higher levels of care but most essentially primary care, not only for urban populations but most essentially rural populations.

A framework that seeks to deliver health outcomes at the population level through a combination of community level monitoring and the provision of continuous care at the local level, will deliver the outlined objectives of UHC. Pro-active care driven methodology, specifically for the rural populations, providing the broadest possible range of healthcare services (including dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses, and management of chronic diseases) at the primary level, will guide the delivery of sustainable healthcare.

Aligned with the national goal of provisioning UHC, research at ICTPH is primarily driven by four focus areas – human resource, technology & infrastructure, interventions, and financing. Population mapping and risk profiling catchment populations coupled with a village-based physician led care delivery outline the ‘pro-active’ care methodology at ICTPH. The model for delivering primary healthcare to remote rural populations in India, as conceptualized by ICTPH provides for a wide range of village based healthcare services ranging from acute care, chronic disease condition management, ophthalmic care, dental care, and population level screening and aggressive management of the health of those individuals that are deemed to be at high risk.

ICTPH is working towards establishing a first-of-its-kind “Managed Care” programme for rural populations, building on their unique primary care delivery model to offer a full-service model of healthcare and financial protection. Evaluating cost-efficiency of end-to-end care delivery in models like ours will add towards the national level experimentation of designing and pricing the optimal universal health cover for its citizens.