Holistic Primary Healthcare at Grassroots – Need for a Multi-Pronged Approach

Out of 22,496 specialists required for Community Health Centres to be fully functional, only 4,156 (18per cent) positions were filled while 11,288 (14per cent) out of the 77,956 nursing staff positions were lying vacant

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By Rajesh Ranjan • Aug 8, 2019


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Most of the 7,000-crore is directed towards the central government's Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which aims to provide an annual cover of 5 lakhs to over 10 crore poor families. While the ambitious scheme is certainly a step forward towards making healthcare more affordable and accessible, the allocation still amounts to only 2.2 per cent of our total budgetary spend.

Low spending, a paucity of healthcare workers and abysmal infrastructure are some critical concerns bedevilling our healthcare sector. According to government figures as on March 31, 2017, 8,286 posts of doctors needed to be filled in Primary Health Centres (PHC). Similarly, out of 22,496 specialists required for Community Health Centres to be fully functional, only 4,156 (18per cent) positions were filled while 11,288 (14per cent) out of the 77,956 nursing staff positions were lying vacant.

A dysfunctional primary healthcare system translates into lack of accessibility, delay in diagnosis and referrals, and a number of preventable deaths especially in rural areas where private healthcare facilities remain limited and unaffordable.

Unfortunately, a disproportionate rise in population has failed to see an equivalent increase in the quality and accessibility of healthcare in India. Increase in spending is just one approach to address this issue of absent healthcare facilities, what we need is a multi-pronged approach to make primary healthcare functional at the grassroots.

Shortage of Healthcare Workers & Health Infrastructure

The objective of a healthy primary healthcare system is to ensure improved health outcomes, the better quality of care, timely diagnosis of diseases as well as prevention. Health systems with strong and fully functional primary healthcare also have significantly reduced burdens on hospitals, secondary and tertiary care providers. However, India's primary healthcare is rendered ineffective in the face of human resource paucity.

The lack of trained doctors and other paramedical staff is one of the biggest hurdles to improving the state of healthcare services in the country, especially in rural and underserved areas. There is just one government doctor for every 10, 189 people, a figure that is woefully short of the WHO recommended a doctor-patient ratio of 1:1000. The nurse-patient ratio is 1:483, compared to the ideal ratio of 1: 4. As it stands, we have a shortage of 600,000 doctors and 2 million nurses.

The problem is compounded by the inadequacy of health infrastructure. The bed-to-people ratio is 1:422 across the country, and is even worse in government hospitals, where it is 1:2239, much less than the WHO recommended 3:1000. Mammoth vacancies bedevilling primary healthcare in rural areas imply that there are villages where health centres are running without doctors and specialists. Intermittently available laboratory services in rural areas are further impacted by shortages of pathologists, technicians and other staff members.

Enhancing the Skills of Primary Healthcare Physicians

Lack of skill and knowledge up-gradation is another problem bogging down primary healthcare in India. According to the Medical Council of India, primary physicians are mandated to complete 30 hours of Continuing Medical Education (CME) once every five years for re-licensure. However, only 20 per cent of physicians in India follow this as it's not legally binding. In the recent past, cases of doctors still prescribing single or double antiretrovirals for HIV/AIDS patients instead of triple combinations which are standard now have been reported. This knowledge gap leads to several problems, like antimicrobial resistance (AMR) and even deaths. Making CMEs mandatory and promoting provision and pursuing of online CME courses must be considered an important task to enable primary healthcare providers to upgrade their skills and knowledge of their field.

Digitizing Rural Healthcare

As healthcare becomes more value-based and patient-centric, digital technology is going to play a key role in preventive healthcare. Primary healthcare can reap rich dividends by adopting digital technology to minimize errors in records and improve the delivery of curative services. Telemedicine centres can be an alternative in improving access to rural populations. Currently, a number of private organizations and NGOs are experimenting by introducing novel telemedicine technology in rural areas. However, we need to adopt this approach on a larger scale to bring real-time benefits to rural populations who have to travel long distances to even access a physician.

Need for Sustainable and Affordable Healthcare Services

Going back to the interim budget, the allocation for the National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) was scaled back by Rs. 120 crores. These diseases comprise a major chunk of life-threatening non-communicable diseases, which are responsible for over 61 per cent of total deaths in India. A budgetary cut for the programme does not paint a favourable picture of the state of healthcare in India, and we need to scale up preventive and promotive healthcare services to avoid life-threatening incidences and reduce the load on understaffed healthcare facilities.

We need to focus on continuous patient monitoring and evaluation with the help of cost-reducing technologies, and take the help of state governments to curate and scale-up sustainable healthcare delivery services to communities that need it the most.

Public-Private Partnerships

One of the ways to improve the state of cash-starved primary healthcare in India is to engineer more public-private partnerships in the field. By tying up with private enterprises, high-impact innovations can be availed to build an equitable healthcare system for underserved populations.

Rajesh Ranjan

C00, WISH (Wadhwani Initiative for sustainable healthcare)

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