India’s healthcare crisis has evoked a policy debate with arguments being made in favour of and against the public and private sector. S.N. Mohanty (‘Fixing healthcare’, IE, November 11) summarises the arguments of both sides very well. He concludes that there is a need to “design the public health system around a new architecture”. What should the new architecture be?
This debate refers to doctors and hospitals alone, with an unquestioning acceptance of the dominant hospital-centred Euro-American model of healthcare developed in the late-19th/early-20th century. This system is a mirage that most countries have been chasing since the 1950s-1960s, and now corporate hospitals have become its icons.
Forty years ago, the doctor and hospital-centred healthcare was internationally recognised as neither desirable nor feasible. The Alma Ata declaration on “Health for All” in 1978 set out a broad set of principles called the Primary Health Care (PHC) approach. It focussed on multi-dimensional, inter-sectoral healthcare, which was to be made available “closest to home”. It required technology to be simple and low cost, while being effective and safe. Primary care, with secondary and tertiary levels also adopting PHC principles, was envisioned as the hub of this sytem. This does not mean lesser secondary/tertiary level services but implies that they must be affordable and accessible, utilising technologies that provide the core of available health knowledge without unnecessary frills. “Decentering” of hospitals implies that primary healthcare providers are in a leadership position to identify local priorities for people’s health and the kind of services individual patients need — much like the family doctor. The experience of health systems in the UK and Thailand — which give this “gatekeeper” role to the primary health workers — show that this approach creates more rational, affordable and comprehensive healthcare systems.
In the name of PHC, what has developed in our public system is a network of primary-level services with varying degrees of efficiency across states. However, with the doctor and institution-centred mindset supervening, there has been in, most states, a complete deskilling of the various primary-level healthcare providers since the 1990s. The male multi-purpose worker (MPW) was weeded out and the auxiliary-nurse-midwife (ANM) has been largely deskilled — she has lost her child-birth related skills to the institutionalisation of births and largely become a clerical keeper of records. The dai, the traditionally skilled provider of maternal and child health services at community level, has been delegitimised. The new addition, the ASHA (Accredited Social Health Activist), is envisaged as a communicator and mobiliser, not as someone with hands-on clinical skills.
The “skilled” healthcare providers now reaching the rural and urban poor are the private sector jhola-chhaap providers of allopathic treatment who have no formal training for it. Together with the chemist, they are the face of the private sector availed in over 50 per cent of illness episodes.
Suggestions in the National Health Policy (NHP) 2017, such as the creation of a public health cadre, introducing nurses and AYUSH practitioners with bridge training as mid-level practitioners at the primary level, revamping the regulatory mechanism and the curriculum of medical education, and promoting medical pluralism, are welcome measures for their potential contribution to the implementation of the PHC . However, a major shift in mindset is required for meaningful outcomes. NHP 2017 promises a major proportion of public expenditure on primary care alone, but it is designed as fragmented bits of schemes and programmes, increasingly only for screening and referral. Insurance-financed coverage will only “assure” secondary and tertiary services from the public and private sector. This will only enhance the crisis.
Making the primary level the hub means enhancing capacities of people/communities/homes for self-care. This implies that primary-level cadres are not just expected to “meet targets” of health programmes but also respond to health needs of patients/populations of their area. The mid-level practitioners should not be merely compromise substitutes of allopathic doctors. They have to understand the local context and perform public health functions at the primary level, reinforced by the strengths of caring and holism of the nursing profession and the AYUSH systems.
The ASHA, the dai with traditional skills and modern hygiene, the re-skilled ANM and the ICDS workers, should together form a multi-skilled team at the village level. The return of the male MPW and the entry of the mid-level provider will strengthen the inter-sectoral collaborations required for health. More doctors have to be inducted into the public system by revamping recruitment procedures and improving conditions.
Secondary/tertiary-level hospitals, public and private, have to be re-structured along PHC principles. A large number of experiments such as Jan Swasthya Sahyog hospital (Bilaspur), the Association of Rural Surgeons of India, RUHSA (Vellore) and SEARCH (Gadchiroli) demonstrate the viability of rational and effective secondary and tertiary services. There is also much to learn from the experiences of Sri Lanka and Thailand. The private sector should be brought under regulations that are based on PHC criteria. Implementing universal healthcare coverage will mean an increase in financial allocations, but more funds alone will not do. Nor will “more of the same” public services. Designing a “new architecture” requires discussion on a PHC Version 2.0.