By Dr. Zeena Johar and Dr. Nachiket Mor 1
India has some of the best quaternary and tertiary care in the world and is gradually getting to acquire a name for itself even in the field of “Medical Tourism”. Secondary care is still a significant challenge but even in several smaller towns and district headquarters there is a growing supply of maternity homes and multi-speciality secondary care facilities. At all of these levels of care, given the large disease burden and the propensity of people to directly approach these facilities even for relatively routine treatments, while availability of capital can sometimes be a barrier, the financial viability is most often not in question. It is our expectation therefore that the supply side problems for higher levels of care could, over time, get resolved even in the absence of concerted policy action. In terms of aggregate supply of qualified physicians there is indeed a problem but given the fact that the physicians trained in alternate systems of medicine are available in sufficient numbers, have legal licenses to practice allopathic medicine, and for the most part are trained in a similar manner, it would appear that a modest amount of training effort directed at them would be able to address this supply constraint for primary care. For higher levels of care, where formal allopathic training would be essential, the number of such physicians that we do have may prove to be adequate.
However, in our view, there are two challenges that need a significant amount of effort and those are in the related domains of primary care and the integration of primary care with higher levels of care. Spain and United Kingdom in the developed world and Thailand, Brazil, and Mexico in the developing world are seen to be good models of healthcare delivery. In all of these systems primary care forms the anchor around which the entire system is built and there is a high level of integration between various levels of care with strong gate-keeping and patient management functions being performed by the primary healthcare providers. Even for India, the High Level Expert Group on Universal Healthcare (HLEG) appointed by the Government of India, which recently submitted its report, has stressed these two ideas and has gone on to recommend that as much as 70% of the total healthcare budget needs to be reserved for primary care.
The actual situation in this regard on the ground in India is very grim. In most parts of the country formal primary care is virtually non-existent. Within the urban context there is a moderate amount of formal primary care available in the form of qualified General Practitioners, ophthalmologists, optometrists, and dentists that people can and do visit. There are also out-patient-departments of secondary and tertiary care urban hospitals that offer primary care services. However, the care is fragmented and for the most part comprises management of visible symptoms rather than the overall health of the individual. In rural India the situation is much worse with neither the private sector nor the government providing this level of care. As a result, most rural residents either do not seek any form of primary care or visit local “medicine men” for advice if they do decide to visit a “doctor”. These “doctors” offer any number of rational and irrational cures, several of which cost a great deal of money (saline bottles being a prime example) for very little benefit, and a few with a strong potential for actual harm (injectibles with un-sterilised needles). Within the system that it seeks to operate, the government does have a guideline for having a local health centre at a 5,000 population level (referred to as a sub-centre) but, the centre does not have a physician as part of the design and therefore cannot prescribe any scheduled drugs; operates with very limited hours; and currently restricts its attention largely to pre-natal and ante-natal care. The formally designated governmental Primary Healthcare Centre is at a 25,000 population level and does have a physician as a part of the design, but is too far for most people and receives such a large volume of patients that the lone physician is reduced to spending anywhere between 10 seconds to a minute per patient. As a consequence even serious illness often remain undiagnosed for an extended period of time and patients end up in large numbers at urban secondary and tertiary care centres often at a very late stage.
It is our belief that the kind of primary care that is needed will not emerge spontaneously in the absence strong implementation effort by the government or a concerted effort by a far sighted corporate sector. These reasons include the tendency of even highly educated individuals to postpone seeking care until seriously ill, resulting in high price elasticity for primary care services. This makes it hard to build financially sustainable and yet rational models of primary healthcare unless one has full control over the entire value chain and can direct the patient appropriately using strong gate-keeping functions.