ICTPH Hypotheses to Address the Challenges Associated with National Health Systems Design for India

By Zeena Johar, President & Member, Board of Directors – ICTPH, and Nachiket Mor, Member, Board of Directors – ICTPH

While maternal and child health and infectious diseases continue to be serious problems in India, an enormous burden of non-communicable diseases exists which needs to be addressed simultaneously.  For example unipolar depression amongst women is now the leading cause of disability in the country, twice that of Cardio Vascular Disease (CVD) and more than three times that of tuberculosis and malaria.  There is however virtually no provision of primary healthcare services in areas of mental health or even in routine areas such as dental care and eye care.  To be effective, primary healthcare needs to integrate a wide variety of curative, preventive, and promotive services in a smooth manner – ranging from mental health, to vision, to dental, to upper respiratory tract infections, to cancer, and to cardio vascular disease.  For example, there are a number of easily observable risk factors such as elevated blood pressure and obesity that need to be tracked at the primary care level for each individual and simple pharmacological and behaviour change interventions implemented in a consistent manner in order to reduce the burden of CVD.

In order to be effective, healthcare needs to be offered close to where people live and healthcare providers need to become a part of the communities that the serve. Primary healthcare providers need to build a comprehensive relationship with each individual that they serve, including geo-location, exposure to risk factors and behavioural traits.   However, there is a limit to what lay health-workers can be asked to provide – there is a need for a strong clinical infrastructure and well trained medical personnel at the village level.  A model of healthcare in which distant facilities are supported entirely by a vast community of poorly paid and barely trained lay health-workers will not be able to deal with these issues in an adequate manner.  While an adequate number of MBBS doctors are not available to serve in remote locations (and perhaps will never be) a combination of MBBS and AYUSH physicians combined with a strong re-certification and continuing medical education programme in primary medicine and a strict protocol based approach towards the provision of primary healthcare combined with real-time audit, can provide a very good solution to the challenges of healthcare personnel.  MBBS doctors based in urban / semi-urban locations focussed on audit and design with AYUSH physicians engaged in front-line provision of healthcare, could be an effective model at the level of each village or a small group of closely clustered villages.  This is also consistent with the existing legal regulations on the provision of healthcare in India and does not require any immediate changes in it. Engagement with the community can take a number of forms, including well trained health extension workers linked directly to the community, schools, local retailers, and tea-stalls each providing an important link with a specific component of the life in the community.

The national healthcare system has to be built with a strong emphasis on a well-functioning primary healthcare with a closely linked secondary and tertiary healthcare system providing effective referral care.  Healthcare financing has to transfer risks to a group of primary, secondary and tertiary health care providers (government or non-government) so that they have an incentive to focus on the entire individual and not just the immediate problem at hand and also have an incentive to control costs. Current fragmented insurance style financing arrangements and symptomatic treatment at the primary healthcare level, needs to be replaced by stronger HMO / ACO type structures which are being paid essentially on a capitation basis for the full package of care.  While the government is ideally placed to offer such integrated services (but only if they are willing to substantially increase their healthcare budgets), if the private sector does have to be involved, these integrated approaches would need to be experimented with and there may be a need to reverse course on pure insurance style arrangements combined with an under-funded public healthcare system that are now coming up in many states, to instead build stronger and more enduring partnerships between insurers and healthcare providers, which are focussed on quality of health outcomes within well-defined populations.

It would be ideal if the government were willing to pay for all healthcare services. However, at current levels of expenditure, even including insurance arrangements being offered by the government, there simply isn’t a sufficient amount being spent on healthcare (current levels are closer to Rs.500 per capita, with more than 50% being spent on secondary and tertiary care while the need is closer to Rs.1500 per capita, with no more than 30% being budgeted for secondary and tertiary care care).  However, if the government is not willing to spend this much money, since the people are already spending on average close to Rs.2500 per capita, there may well be a need to develop a more carefully designed user fee model to ensure that healthcare is provided universally by putting to use at least a part of that expenditure and organising it better so that pre-payment replaces out-of-pocket payments at the point of service.  Even if pre-payment becomes difficult to implement because of challenges in the insurance market, a potential model for out-of-pocket user fees at the primary level could be to define poverty in terms of exposure to risk factors and some acute illnesses rather than in income terms (easier to observe and addresses a core problem of intra-household poverty and old-age poverty) and make those treatments free while continuing to charge for routine healthcare, vision, and dental care.
 
At the IKP Centre for Technologies in Public Health (www.ictph.org.in) the focus of the research work is to think through these challenges in more detail, develop viable hypotheses, and then to test them with field based partners such as Sughavazhvu (www.sughavazhvu.co.in) and others that are interested. For the purposes of clarity and focus these research efforts are classified into four distinct components:

1. Human Resources: this component addresses all of the challenges related to recruitment, training, and performance management of all of personnel including physicians and health extension workers.

2. Infrastructure: this component addresses all of the challenges related to the building, technology, and diagnostics associated with this design.

3. Interventions: this component addresses all of the challenges relating to the development of the curative, preventive, and promotive protocols required to deliver comprehensive “wellness” interventions, both through the formal clinical infrastructure as well as all of the community engagement points such as health extension workers, schools, local retailers, and local tea-stalls.

4. Financing: this component addresses all of the challenges related to constructing the referral pathways for advanced care, financing, and user-fees.