Primary healthcare in most Indian states is in shambles. This is despite a national flagship programme, National Rural Health Mission (NRHM), having run for more than a decade and having pumped public investments of over Rs 1.3 lakh crores from 2005-06 to 2014-15. NRHM, which was aimed at strengthening government health delivery system in rural areas with a focus on the primary care, was launched in 2005 with much fanfare and hope. Then, the commitment of central political leadership to the health sector was high; and so were ambitions. Those ambitions were backed by greater availability of public funding which was made possible by faster economy growth.
NRHM repacked many existing Central programmes such as reproductive and child health, immunisation, contraception, training, etc. as well as supported many new activities such as training of new cadre of health workers (ASHAs), upgradation of public health facilities, constitution of patient welfare committees (RKS), etc. — all in a flexible, decentralised manner.
Despite all this, a special health survey conducted by the National Sample Survey Organisation in 2014 reports that only 28 per cent of total non-hospitalised cases in rural areas are actually treated by public health facilities. This implies that a vast majority of rural folks needing non-hospitalised care actually end up going to private providers, paying out of their pockets at the point of care. It is no surprise that 60 per cent of total healthcare expenditure in India is private expenditure and most of it is out-of-pocket, with pernicious effects on the finances of poorer households.
The party in power at the Centre has now changed; and so have the policymakers who were initially involved in the design and roll out of NRHM. The officials in health ministry may still find some solace in whatever NRHM could achieve, particularly in increasing institutional deliveries. But the fact remains that the programme performed much below its promised goals. As is typically the case, the health ministry may blame the states for the tardy implementation of NRHM. The states too may have their points of view: the poorer states may cite low implementation capacity vis-à-vis the complexity of the sector while the richer states may find fault with the programme design. This blame game has no winners but only losers — the common people.
One big lesson that emerged from the experience of NRHM is that the states have to be in driver’s seat in prioritising, designing, financing and implementing the primary care agenda. The Central government can at best provide some financial incentives and technical guidance to states that prioritise the primary care. But a call to strengthen the primary care is that of states.
The legacy of a weak primary healthcare system in the country could be considered as an opportunity to move to an innovative, low-cost care delivery model, which is made possible due to technological innovations. For example, tele-consultation, tele-medicine and tele-radiology have the potential to overcome access barriers, economise on the scarcer factors such as doctors by reducing patients’ need to have face-to-face encounter with doctors, improve patient satisfaction and so forth. To give another example, a trained nurse, guided by computer algorithms, can be made capable to evaluate and prescribe drugs for certain conditions. Similarly, technology can be deployed in many other ways to strengthen accountability, bring transparency, make field workers more effective and so forth. A transformative, low-cost delivery model has to integrate various innovative pieces into developing a robust primary care system that also addresses the emerging non-communicable disease burden among population. A primary care system ought to be the first point of contact for all medical needs (preventive, promotive and curative care) of the population, and also need to serve as the referral point for guiding the patient to higher level health facilities.
What is needed is a few states taking a big leap in this direction. The states that move first will need to pilot a few low-cost care delivery models in order to discover an appropriate model that can be taken to scale. Those states need to increase their health spending, which is woefully low at present, is a well-known fact. But bypassing this necessary pilot phase before states step up their health spending will be a big mistake, leading to a waste of government funding, capacity and time.
It is in the Central government’s own interest to see the states prioritise primary healthcare as that will help the country meet its health-related commitment under sustainable development goals. Further, when the Central government is strengthening the tertiary care in the country by setting up new AIIMS hospitals as well as new cancer institutes, a robust primary care is also needed from the health system efficiency perspective — to mitigate the flow of patients to hospitals by “catching” them early. So even in the primary healthcare, the Central government does have a role: to ensure that at least a few states prioritise primary healthcare.
Once a few states have taken the lead in redesigning their primary care delivery system, the pulls and pressures that usually accompany any development process, will necessitate the lagging states to follow suit and also benefit from cross-learnings.
