Just improving access to healthcare is not enough to ensure better outcomes. India must invest in primary care with the objective of improving both access and quality of care
The Union government has intensified efforts to focus on health programmes to provide good health care to every citizen of India. Recently, it launched a major programme to achieve the target of universal health coverage. In the last 60 years, several such programmes and policies in the health sector were initiated to expand access to health services, especially in rural areas.
However, the results of many survey and research data show that these efforts couldn’t achieve the ultimate objective of providing good health to everyone. Maternal and infant mortality rates could not be improved to the levels necessary to achieve targets in stipulated timeframes.
Health schemes have increased access to health facilities and the number of primary care centres has increased manifold. The increase in number of health centres has improved access even in remote areas. An increase in the number of institutional deliveries has resulted in a decrease in maternal mortality to some extent in 2016-07. But due to poor quality and inadequate services, the total number of deaths has gone up. Around five million people die every year — almost one third of them in India (16 lakh) — due to inadequate health care, according to a new analysis published in the British medical journal The Lancet.
According to the sample registration system (SRS) data, the maternal mortality rate has declined to 130 in 2014-16 from 167 in 2011-13 — a significant improvement on a parameter used widely by analysts and developmental economists to rate a country’s health sector progress. The Socio-Economic Review of 2016-2017 says that health infrastructure and services are being constantly improved and enhanced to increase access, availability and affordability.
New schemes to reduce maternal mortality rates
In 2005, the United Progressive Alliance (UPA) government launched the National Rural Health Mission (NRHM) aimed at improving the delivery of health services in rural areas. Several significant changes were made in rural health infrastructure. The programme resulted in improving maternal and child health significantly.
The scheme was launched to strengthen healthcare infrastructure and to boost failing public health indicators in rural areas. By 2013, the considerable success of the mission prompted the Union Cabinet to set up the National Urban Health Mission (NUHM). Both, the NRHM and the NUHM currently exist as sub-missions of the National Health Mission (NHM). To complement NRHM, the UPA government then launched the national insurance programme — Rashtriya Swasthya Beema Yojana (RSYB) in 2008. The idea was to reduce out-of-pocket expenditure at the time of hospitalisation. RSYB covered around 4 crore families and about 19 crore individuals, benefiting over 1.4 crore individuals cumulatively. The programme also attracted criticism for many reasons. Due to the increase in utilisation, there was a need to increase budget allocation; so insurance companies succeeded in hiking premium rates. The low enrolment, inadequate insurance cover and the lack of coverage for outpatient costs are main reasons that the poor are still forced to pay for health care.
According to a 2017 study published in Social Science Medicine, the RSYB did not lead to any reduction in the out-of-pocket expenditure of 150 million beneficiaries. Due to poor implementation, financial constraints and a lack of commitment by different states, the objective of the programme couldn’t be achieved as conceived. The National Democratic Alliance (NDA) government, after coming to power in 2014, also introduced structural reforms with the objective of reforming the health and social structure, and also announced the National Health Policy in 2017 (NHP2017).
National Health Policy
The NHP proposed an ambitious health agenda, especially with respect to the enhancement of public spending on health from the current level of 1.15 per cent of Gross Domestic Product to 2.5 per cent by 2025. In addition, it also proposed to increase health spending of states to over 8 per cent of their budget by 2020. India’s public expenditure on health is rising, but it is very low compared to the increasing population — an addition of 2.6 crores each year. NHP focused on primary care services and continuity of services, besides a ‘Health for All’ approach. It also emphasised that the Right to Health cannot be perceived without an improvement in basic health infrastructure like doctor-patient ratio, patient- bed ratio and nurses-patient ratio.
To achieve NHP objectives, the government in September 2018 launched an ambitious health insurance scheme — Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). According to recent data, the scheme has already benefited 5 lakh people.
When fully rolled out, the health protection scheme will cover 10 crore poor and vulnerable families (about 50 crore people) providing up to Rs five lakh per family per year for secondary and tertiary hospitalisation care. It is expected that with the implementation of the scheme, out-of-pocket expenditure will be reduced. Every person enrolled in the Social Economic Caste Census (SECC) database will be automatically included in the scheme. According to the SECC survey 2011, there were 24.49 crore households, out of which, 17.97 crores were rural households and 6.51 crores were urban household. The beneficiaries can avail the scheme in both, public and empanelled private hospitals. The payment for the bill will be made on package basis, which will be defined by the government in advance.
The scheme been criticised on the grounds that its focus is on secondary and tertiary care while in reality, dependency on primary health care is more. In addition, hospital care package prices are too low to encourage private hospitals. AB-PMJAY may be providing some relief to the poor seeking treatment in hospitals, but it can’t strengthen primary health care and improve curative care facilities and reduce the burden for hospitalisation. Though to address primary care, the scheme includes opening of wellness centres but results from these centres are yet to be seen.
Addressing quality of care
Poor quality of care is responsible for high maternal mortality rates. Access to health services, which is the prime focus of Universal Health Care (UHC), can’t ensure achieving the Sustainable Development Goals, according to the report of The Lancet Global Health Commission on High Quality Health Systems, published in The Lancet in September 2018. The study was part of a two-year project that brought together academics, policy-makers and health systems experts from 18 countries to examine how to measure and improve health systems’ quality worldwide.
Almost 122 Indians per 100,000 die due to poor quality of care each year, the study said, showing up India’s death rate due to poor care quality worse than that of Brazil (74), Russia (91), China (46) and South Africa (93) and even its neighbours Pakistan (119), Nepal (93), Bangladesh (57) and Sri Lanka (51).
Poor care quality leads to more deaths than insufficient access to healthcare — 16 lakh Indians died due to poor quality of care in 2016, nearly twice as many as due to non-utilisation of healthcare services (838,000 persons). Is providing care without ensuring the quality of health services effective? Some 24 lakh Indians die of treatable conditions every year, the worst situation among 136 nations studied for a report published in The Lancet.
The findings of another qualitative study about delivery care done by the Public Health Foundation of India in Uttar Pradesh also finds that the safety of the poor is being compromised due to lack of quality care like poor hand hygiene, usage of unsterilised instruments and inadequate clinical care like the lack of monitoring of labour progression in public health facilities. Apart from compromising clinical care, the study findings also observed compromising privacy, incidence of abuse and demand for informal payment.
At the global level, data also shows that deaths due to poor quality care are more than HIV/AIDS or diabetes for that matter. The total number of deaths from poor-quality care globally — 50 lakh per year — is estimated to be five times as many as the annual global deaths from HIV/AIDS (10 lakh) and nearly three times more than deaths from diabetes (14 lakh), according to the Lancet study.
Given the current global focus on UHC, the Commission found that expanded healthcare coverage does not always mean better quality. The central role of quality is not yet sufficiently recognised in the global discourse on UHC and is underappreciated in many countries, the report says. Citing the example of Janani Suraksha Yojana, the survey, mentioned that a cash incentive programme for birthing facility, which massively increased delivery facility, did not measurably reduce maternal or newborn mortality.
Better health with quality of care
India has an elaborative health care delivery system for rural areas but the system is not able to deliver quality care. The Primary Health Centre (PHC) is the first point of contact between a village community and the health system. The central PHC is headed by a medical officer and acts as a referral centre system for six sub centres, which provide curative and preventive services for 20,000 to 30,000 people.
To cover such a large population, these centres should be equipped with at least six beds, a doctor and sufficient manpower, besides having enough stock of medicines and equipment to provide good and hygienic delivery care. However, the manpower and other facilities needed to run these centres are alarmingly low. Patients who reach these centres are not sure about the kind of care they require.
For providing good quality care, we need to have sufficient resources for infrastructure. Primary centres should be well-equipped with doctors, medicines and equipment for diagnosis. In 24 states, instances of non-availability of essential drugs were observed by an audit by the Comptroller and Auditor General of India (CAG). Further, there was a 24 per cent-38 per cent shortfall in the availability of medical personnel at primary health centres, sub centres, and community health centres in 28 states/union territories of India, as per the CAG report.
It is clear that just improving access to healthcare is not enough to ensure better outcomes. As the study on Janani Suruksha Yojana observed: “It has increased facility of delivery but did not measurably reduce maternal or newborn mortality.” While it led to 50 million births in health facilities, many of them occurred in primary care centres that did not have sufficiently skilled staff to address maternal and newborn complications. It is essential to invest in primary care and do so with the objective of improving both access and quality of care. Only this approach can help India achieve the dream of better health for all.
The author is Head, CMS Advocacy. She writes on social and development issues
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