Comprehensive Primary Health Care, the only way forward for Universal Health Coverage?

Based on recent developments, and announcements in the public domain, including deliberations at the recent Indian Public Health Association Conference 2022 held at Pune, India from 23 Sep to 25 Sep 2022, it emerges that there is a welcome change in the planned approach of the Govt of India, possibly keeping in view the desire for Universal Health Coverage to which India is a signatory at the United Nations in 2019.

https://www.who.int/news/item/23-09-2019-who-welcomes-landmark-un-declaration-on-universal-health-coverage

It can be inferred that there is a paradigm shift to “All Services for All people” from the earlier “Some Services for Some People, More for those in need“.

By championing the Health and Wellness Centre concept, by pushing for health insurance provision at the family level, by focusing on the prevention paradigm, through the Ayushman Bharat scheme, the Govt of India apparently is moving towards the long awaited wellness concept instead of focusing on curing illnesses alone. Someday it will be time for the people too, to realise and appreciate that they now need to take their health in their own hands and be responsible themselves too, to lead healthy lives!

Reportedly, budgetary allocation is no longer being done disease or group wise (i.e not separately for Diabetes / Hypertension or Mother and child health or Mental health etc). The Central Govt has consolidated the myriad accounts that existed earlier, to streamline the entire process, and bring in more transparency and accountability. During the COVID pandemic, with increased awareness of all things related to health, many may now know that “Health” in India, is a ‘State’ subject, wherein State Govts assume responsibility for healthcare for people in their State, and where the States too have to contribute for Health budgets, and not just expend monies from the Central Govt. And more importantly, that on ground expenditure of Health budgets is done in a major proportion by the State Govts rather than by a distant ‘Kendriya Sarkar’ (central govt).

Reportedly, in 2022, more than INR 1.5 lakhs crores have been firmly allocated for infrastructure in the States under the Ayushman Bharat Health Infrastructure Mission & Fifteenth Finance Commission for the next four years, being monitored by the Govt of India through a dedicated web based Project Management System portal. 

It has clearly been communicated to the healthcare machinery & bureaucracy at the State levels, that the Govt of India is focusing on infrastructure while leaving provision of manpower and planning and delivery of healthcare services to the States as per the action plans for Comprehensive Primary Health Care.

Guidelines for Public Health cadres have also been promulgated by the central Govt in 2022. New components for the primary healthcare system such as Critical Care Blocks, and Block Public Health Units have been introduced. The States need to seize this opportunity (truly carpe diem), and revitalize their healthcare systems, leapfrogging over the infrastructure thrust of the central govt and emancipating their own peoples through proactive initiatives.

Our States must appreciate that this keeping pace with the aspirations of the people and a global thrust towards Universal Health Coverage, needs to be done on an urgent basis.

A potential approach with great promise, is to co-opt the extensive intellectual resource pool of Govt medical colleges to constitute state level think tanks to chart the way ahead.

For this, the Department of Medical Education and the Department of Public Health / National Health Mission team at the State level, need to work together, to collaborate, to synergise, and actually walk the talk! These both serve the same clientele and answer to the same hierarchy. Its just the silo walls between medical academia and the primary healthcare that need to be demolished. Easier said than done!

Think Global, Act Local!  Our people need to become vocal about this… thus the envisaged crucial and increasing role of Panchayati Raj Institutions and an empowered electorate to educate themselves.

Yeh Dil Maange More…. Till this is the clarion call of society, the pace will be laggardly and sluggish, despite best intentions of the Govt at the Centre.

Hence in summary, for the discerning reader, especially those in the corporate CSR  or philanthropic sector the relevant inferences  and actionable inputs for the future are as follows:-

  1. Comprehensive Primary Health Care (CPHC) is the only viable approach for the next 25 years at least, with all its components, made available to all people, including in cities (and not just in cities).
  2. Healthcare needs to be planned for hyperlocal delivery and finetuned to situational requirements and circumstances through a participatory approach including the local medical colleges and healthcare system and also NGOs and most importantly the people (and not just their elected representatives).
  3. Tribal areas, hilly areas, mountainous areas, LWE affected areas, riverine areas, deserts, peri urban underserved agglomerations, etc etc require specific approaches customised to their peculiar situations.
  4. A one size fits all, prescriptive , template based approach in healthcare will not work, and will definitely not sustain.
  5. Standalone vertical healthcare programs will eventually require to be subsumed with the CPHC approach.
  6. Seamless integration of activities, capabilities and facilities across the primary healthcare system, with decentralized implementation and dashboard based monitoring is the future. The Ayushman Bharat Digital Health ID will be the keystone of the ecosystem and will be a game changer for patient and healthcare provider alike
  7. Health & Wellness Centres should become the preferred mode of delivery of CPHC, with an emphasis on health promotion activities. The shift to seek to deliver or obtain only disease management through these HWCs needs to be resisted at all levels, despite the evident temptation.
  8. Overly ambitious expectations should not be retained for the HWCs. The service delivery depends entirely on a newly created cadre with unproven skillsets (the Community Health Officer) placed in challenging circumstances. These CHOs will require consistent technical support and handholding, besides motivation and morale boosting. Effective mentoring by appropriately qualified healthcare professionals is essential
  9. The AAA troika (ASHA, Auxiliary Nurse Midwife, Anganwadi Worker) are the most powerful women in India today, having the power to bring about change, and transform society. Our Hon’ble Prime Minister had aptly stated, possibly during his Independence Day speech of 2018, that these frontline workers need recognition from the community and the healthcare system, to motivate them (and of course, appropriate remuneration too). Just for the record, in 2022 ASHA workers have been conferred the WHO Director-General’s Global Health Leaders’ Award in recognition of their valuable health services to the people in rural areas.
  10. Capacity building and capacity maintenance of personnel at the peripheral echelons of the primary healthcare system, through academic partnerships and mentoring from the medical college network should be preferred to promote ownership and a feeling of belonging and involvement. NGOs and other international agencies can play a major role in facilitating this process of capacity building and its sustenance.
  11. Community mobilization and participation are going to become the key areas of focus in improving health of the nation, through strengthening of the Panchayati Raj Institutions.
  12. Human beings do not exist in isolation. They need potable water, safe food, clean air, comfortable habitation, hygienic surroundings, livelihoods , education, entertainment, to be (and remain) healthy.   
  13. Lateral integration with Swacch Bharat Mission is essential for any health focused initiatives. Health cannot exist in isolation. Health flourishes best with hygiene and sanitation- Swachh Bharat, Swasth Bharat. 
  14. There cannot be health without proper nutrition. The Poshan (nutrition) Abhiyaan is a multi-ministerial convergence mission with the vision to ensure attainment of malnutrition free India soon. The time frame for achievement of this goal may be unrealistic, however it is inescapable that unless we have holistic development and adequate nutrition for pregnant women, mothers and children, society cannot make the required strides towards an India wanting to own the 21st century.
  15. Human resources management, with a focus on attraction and retention of skilled personnel, needs to be accorded due importance and priority. Despite all technological advances, which patient or patient’s family in need of healthcare assistance will be truly satisfied without an engagement with a healthcare worker in person. Hi-Tech is fine, High-touch will remain equally and more important probably.
  16. Public Health personnel are to be compartmentalized into (a) healthcare professionals, (b) administrative professionals and (c) management professionals, (each group catering to different aspects of public health), instead of the current situation where Public Health graduates with non medical backgrounds are endeavouring to perform all roles with varying degrees of competence and capability. 
  17. Give healthcare workers of all categories, especially clinical doctors, the respect and recognition that is their due, and appropriately reimburse them for it. Ensure that remuneration for medical doctors is commensurate with Central Govt scales to ensure uniformity and to stem rural – urban ‘brain drain’.
  18. Administrative personnel must focus on working conditions at healthcare facilities and also not assign unrealistic workloads to Healthcare Workers at all levels including medical professionals.
  19. Regulation of the role and scope of NGOs should be a reality in the near future, to ensure not just synchronicity with the Govt’s vision for healthcare and the people’s aspirations for healthy lives, but also for compliance with public health ethics and population rights. 
  20.  Technological methods and innovations including apps and HMIS software in the arena of public health may be registered centrally, to ensure benefit across the nation. States may be encouraged to share plans and proposals for innovations in advance, to ensure no redundancy or overlap with existing innovations, which can then be scaled up and rolled out nationally by a coordinated initiative, instead of disjointed multiple approaches. With health data portability being essential in the future, it is prudent for this to be implemented sooner than later.

Please do connect with me for any further discussion or insight that you may desire. I will be glad to help your team chart out action plans to tackle areas of your interest in population health. I happily collaborate with anyone and everyone in the greater interest of Health for All!

The time for action is now, if we want to see the India we dream of at 100 years post Independence.

As a disclaimer, these above are my personal views based on an unbiased professional assessment of the current situation. And are not intended to be critical of, or reflective in any way or to be construed as representing any Govt policy.

Published by Delta Zulu Consultancy

I am a Public Health Specialist with a passion for sustainable promotion of human co-existence with the environment! My areas of interest and expertise are Health Risk Communication and Community Engagement, Food Safety, Environmental Medicine and Mass Gathering Medicine. I believe in leveraging the power of technology to capture the imagination of people to inspire them to achieve their health potential, in a sustainable manner. I aspire to empower my partners and motivate stake holders to consistently seek 'work around' solutions, while hoping to achieve an utopian ideal balance.

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