Comprehensive Primary Care Needs Cohesive Partnerships

Public spending on healthcare in India is abysmally low and hovers around 1-1.5 per cent. The shocking truth is that less than half of this is spent on primary care. Without a due focus on comprehensive primary and preventive care, India cannot have a sustainable health system to provide Universal Health Coverage (UHC). The expanse and expertise of private sector healthcare providers and the diagnostic segment can be leveraged strategically for improving infrastructure, boosting investments in the sector, transforming access to quality care by standardising diagnostic and screening procedures. The private sector can also help in capacity building of the primary healthcare workforce, developing referral mechanism and leveraging IT-based solutions like telemedicine and tele-diagnostics. 

Also, to increase in allocation and investments in health, effective utilisation of funds is of utmost importance. Thus well-strategized investments in primary health can greatly help reduce the burden on secondary and tertiary care and reduce the overall cost of care on the healthcare system.

Studies indicate that hospitalisation ratio in a district is negatively correlated to primary care usage - a 10 per cent increase in primary care usage leads to a 6 per cent reduction in hospitalisation. The National Health Policy 2017 proposed Private-Public Partnerships (PPPs) for rural and urban primary health services with not-for-profit and for-profit providers respectively, in areas of skill development and capacity building, provision of mental health and disaster management. Nearly 70 per cent of outpatient primary care is now provided in private clinics and health centres both in rural and urban India.

With Ayushman Bharat - Pradhan Mantri Jan AarogyaYojna (AB – PMJAY) and availability of Health and Wellness Centres (HWCs) completing the first year of implementation, India has inched closer to its intended targets of Universal Health Coverage and Sustainable Development Goals. The AB-PMJAY scheme that has been introduced on 23rd September 2018 has been able to impart healthcare to nearly 17 million patients in one year since inception. The 21,000 AB-HWCs, which cover a target population of 5 crores, has seen a footfall of 1,70,63,522  patients till date. According to the latest figures, more than 1.5 crore people have been screened for hypertension (more than 70 lakh people put on treatment), around 1.3 crores screened for diabetes (more than 31 lakhs on treatment) and more than 76 lakhs have been screened for oral cavity cancer, of which 10,218 people are on treatment. Of the 53 lakh, women who underwent screening for breast cancer through these centres, around 9,700 women are on treatment. In the case of cervical cancer screening, around 10,000 women among the 37 lakh who were screened are on treatment. Dr Harsh Vardhan, Hon’ble Minister for Health & Family Welfare has pointed out that more than 1.6 crore people received free medicines and around 49 lakh availed diagnostic services through the programme. In order to expand this number, it is imperative that large tertiary private hospitals also admit patients under this scheme. This is currently not happening as the rates of many procedures are far too low for the private players to offer their services. So far the government has set prices for sophisticated procedures in a most arbitrary and an ad-hoc manner. The government needs to carry out immediately an exercise in which the cost of each medical procedure is determined in a scientific manner. The National Health Authority (NHA) has formed a Committee under the stewardship of Dr Arun Gupta to carry out such an exercise. It is hoped that this Committee takes inputs from leading players in the industry and arrives at realistic cost estimates of different procedures. This is the need of the hour as a responsible country like India needs to know the real cost of every healthcare procedure. 

Given the scale of the AB-HWC program and constraints around financial and human resource availability, private providers can play a key role in effectively furthering the Government’s primary care agenda. The private sector can help to design and develop innovative PPP programs to affordably diagnose and monitor a larger number of patients in under-served areas for the training of human resources. Tata Trust’s programmes such as ECHO training for TB and Mental health or a program to train resources at Urban PHCs are the innovative models which can be scaled up. Technological support in the areas of NCD screening and telemedicine can also be provided by the private players. If we talk about accountable financing then Rajasthan's ‘Utkrisht Bonds’ provides the way forward. 

We can learn from Wipro’s GE’s model Health and Wellness centre to efficiently operate the Health and Wellness centres. 

Over the next 2-3 years, 150,000 HWCs are to be established across the country- a target that the government cannot achieve unless the private sector is involved in a big way, given that 70 per cent of all healthcare services are currently delivered by the private sector. 

At the coming Annual Summit of NATHEALTH, stakeholders would be deliberating in details on the private sector’s contribution and scope of partnerships in terms of finances, trained manpower, technical resources, best in class technology and infrastructure up-gradation and technology-enabled solutions to reach the last mile. 

The government has taken several steps on the national level to tackle the growing prevalence of lifestyle diseases like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) and the National Programme for Health Care of Elderly. But, NCDs demand sustained long-term care. 

To tackle the burden of NCDs, a multi-pronged approach must be devised, with key elements including 

• Awareness, education, health promotion and prevention of NCDs through lifestyle modifications, appropriate nutrition, better health-seeking behaviour and adherence to screening and treatment 
• Early diagnosis through mass scale screening of adults above the age of 30 years and access to affordable primary care, which will act as a gatekeeping strategy to reduce the economic burden and the load on secondary and tertiary care
• Establishing a robust referral system that will ensure timely intervention of specialists 

The healthcare industry has benefitted significantly from technological advancements that have also led to an increasing preference for evidence-based treatment. Today, diagnostics influence about 70 per cent of all healthcare decisions. But, we spend only 3-5 per cent of the total healthcare spending on diagnostic tests. 

An aggregation of unorganized players and organized players have the potential to face the current challenges and meet the growing demands of the population. The segment will also be better equipped to meet the current and future demands with higher spend on early detection and screening. There is a need to focus on awareness and preventive care and increasing e-commerce based offerings.

Given India’s large population base, geographic spread, rising dual burden of diseases and current status of the healthcare system, investments- neither from the government nor from the private sector can alone meet the needs of the population. The public and private sector must join hands for improving investments, expanding infrastructure and capacity building of the healthcare workforce. 

The Government has committed to increasing public spend on healthcare from the current 1.5 per cent (2018-19) to 2.5 per cent by 2025- an increase of more than 300 per cent over 7-8 years. This calls for a steady increase in funding for healthcare year-on-year. Apart from the public funds, the private sector has a substantial share, accounting for almost 70 per cent of the overall health spending. Appropriate policy measures and fiscal incentives to encourage private sector investment are prudent. 

(Author is past President of NATHEALTH & Chairman and Managing Director, Dr Lal Path Labs)

Dr Arvind Lal

Guest Author The author was Past President, NATHEALTH & now Chairman and Managing Director, Dr Lal Path Labs.