Contributed by Dr. Naresh Trehan,
Chairman, CII National Committee on Healthcare and,
Chairman and MD, Medanta- The Medicity
The broken healthcare delivery chain
Primary health provision was recognized as a tool for attainment of ‘health for all’ more than three decades ago by the Alma-Ata declaration. While looking for answers to why it has not yet been attained, it is realized that we need a multi-dimensional approach to provide delivery to 1.2 billion people, with varied disease patterns and medical needs. Today patients in the villages often travel over 100 kms to access basic healthcare services. Access to care is also limited by the low affordability in the population.
For a common citizen in India basic needs of potable water, sanitation, basic hygiene and healthcare have become a far-fetched dream. There are 24.7 crore households in India, out of which 68% reside in rural India and the remaining account for urban population. It is alarming that out of the total households, 23.7% stay in mud houses and 53% do not have access to toilet facilities within the household. Only 43.5% of Indian population has access to safe drinking water and the World Bank estimates that 21% of communicable diseases in India are related to unsafe water. Adding to this issue is the sanitation crisis; 814 million Indians do not have access to sanitation services.
In order to provide for these basic rights, India needs to address issues at each level of the healthcare delivery chain in terms of infrastructure and manpower. To meet the basic healthcare needs, the National Rural health Mission (NRHM) was launched in 2005. ASHA (Accredited Social Health Activist) workers were envisaged under the NRHM to create awareness and provide information to the community on determinants of health such as nutrition, basic sanitation and hygiene practices, community mobilization, provision of primary medical care, etc. The Ministry of Health and Family welfare recommends mandatory training for ASHA workers, however almost half of them were educated below secondary school level and has poor knowledge regarding immediate referral conditions While, they were enrolled to act as a bridge between the community and the available healthcare system, but due to these shortcomings, they have not been able to fill the void in the system.
Though the network of delivery settings is in place, each of them is working in isolation, leading to increased medical cost burden and an imbalance in the patient inflow catered by these healthcare facilities. Availability of skilled medical, nursing, paramedical and allied workforce is another roadblock which is adding to the challenge of the broken healthcare delivery chain in India. There is a need to streamline the value chain of the delivery system in order to provide a comprehensive delivery system.
The way forward While devising a prescription for Indian healthcare, it becomes inevitable to look at the challenges of the sector holistically and address issues not just relevant to hospitals, but create an enabling environment which can propel growth. Due to the massive reach of the Government and availability of manpower and infrastructure at rural level, primary care needs can be addressed by the government economically and PPP models can be implemented where expertise and resources of the private sector could be utilized.
Augmenting and building the capacity of existing workforce can offset a significant amount of the disease burden at the primary level and result in better health outcomes. For instance, ASHA workers which have a massive outreach to the population can act as eyes and ears for the health systems. Imparting requisite skill set to them can act as a change agent for improving the health outcomes.
In continuation with the skill development process the Healthcare Sector Skill Council (HSCC), was launched and started recently in partnership with CII and Public & Private providers. It aims at developing curriculum and content for the allied health workforce. This would aid in providing the right skill sets to paramedical workforce and ensure that quality medical treatment is delivered to the patient.
Public Private Partnership models could be leveraged in strengthening the secondary and tertiary care levels of the healthcare value chain by bringing together the operational and managerial efficiencies of the private sector. This will aid in better utilization of already existing infrastructure of the public sector and result in improved utilization of assets and services.
The recent spurt in public health insurance schemes will act as a catalyst in improving the accessibility of tertiary care to a large segment of underserved population. The government’s role of being a payer has the dual advantage of allowing patients the choice of treatment in the private sector and also provides the government the flexibility to focus on primary healthcare infrastructure.
The need of the hour is also to identify and strengthen the support pillars of healthcare delivery system which is so far missing from the larger discourse. These include production of quality manpower, technology enabled solutions like mobile health, and adoption of low cost drugs and vaccines. While some such models have already been implemented, the scale at which they can be utilized needs to be tapped by the country. Many pilot studies are already being done on usage of mobile and information technologies to increase accessibility in rural areas, and Tier-I and Tier-II cities. What is also encouraging is that most of the medical innovation is now taking place in the smaller cities and towns where the need for quality healthcare is most acute.
Going forward the action agenda is to foster a multi stakeholder collaborative approach with a common objective of providing affordable healthcare to masses. To achieve this, we need to collectively think beyond the traditional and implement unconventional solutions in the Indian health system.