The primary care fault line

Given its scale and scope, a redesigned primary care system will necessitate a huge step-up in government health spending.

Updated - September 20, 2016 05:19 pm IST

Published - June 05, 2016 12:13 am IST

It is well known that government health spending in India is woefully low. And, India comes out poorly in comparison to its peers regardless of the indicator used — as a share of GDP (1.3 per cent) or as a share in total government spending (4.8 per cent) or as a per-capita government health spending (less than $20). Undoubtedly, the government needs to increase its health spending. But for a huge step-up in its health spending, it needs to get the delivery system — particularly at the primary care level — right.

Boosting confidence Low government health spending in India is the result of the faulty design of its delivery system, particularly the primary care system, on at least three counts: first, the system is not designed to address much of the health-care needs of the population at the primary care level; it is totally oblivious to the emerging burden of non-communicable diseases (NCDs). Second, the primary care design is doctor-centric and built on the unrealistic assumption about the availability of human resource in the sector. Consequently, there are huge vacancies across all cadres of health workers. For example, the share of vacant positions of doctors in primary health centres is over 25 per cent. Third, the government health delivery system in many States has a reputation of poor management and governance because of weak incentives and loose accountability mechanisms; the system is designed to focus on inputs instead of on quality care and improving health outcomes. It is little wonder then that a vast majority of the cases (79 per cent in urban areas and 72 per cent in rural areas) go to private providers for non-hospitalised care, with all its pernicious consequences notably high household spending.

Even a fairly ambitious National Rural Health Mission failed to make much of a dent on government health financing despite running for over a decade. Because what is being asked by health experts of government health spending is not a chump change but something of the order of doubling of the government’s share in GDP from 1.3 per cent at present to upwards of 2.5 per cent of GDP over the next few years.

Thus, the government health delivery system is trapped in a low equilibrium where low confidence in the primary care system is resulting in low funding of the sector. The government currently spends less than $10 per capita on primary care when any decent system would require several multiples of it. From the health system perspective, any additional investment that goes into developing a robust primary care system is worth it. What is needed to break out of this low equilibrium is a higher level of political commitment to redesign the primary care system.

The primary care system in India needs a radical transformation to provide care at the household, community and health facility levels for a wide range of services including early screening and detection of NCDs, and management of its risk factors so that the system gets used by the majority of the population. Further, the new design ought to be paramedic-centric and performance-oriented. It should leverage the power of Information Technology (IT) that has the potential to overcome access barriers, economise on the scarce factors such as doctors and improve patient satisfaction. IT-based interventions, such as e.g., tele-consultation, telemedicine, and teleradiology, are fast becoming the reality. A transformative delivery model has to integrate these innovative components into a primary care system that not only acts as the first point of contact for all medical needs (preventive, promotive and curative care), of the population, but also serves as the referral point for higher level health facilities.

States in the driver’s seat States play a major role both in the delivery and financing of health services. Following the 14th Finance Commission recommendations, the role of States in the financing and delivery of primary health care has become even more important.

While learning from the experience of countries such as Thailand and Turkey, States need to do their own experiments. The idea that States test Universal Health Care (UHC) pilots was actually mooted in the 12th Five Year plan but it never got off the ground. But that doesn’t diminish its relevance. States could partner with the international development agencies to test a few primary care pilots but the onus is on Sstates to ensure that such pilots are indeed the ones that are scalable and sustainable.

Given its scale and scope, a redesigned primary care system will necessitate a huge step-up in government health spending. So, health advocacy needs to focus on asking States to prioritise health, getting on with pilots, and coming up with their own design blueprints and road maps before asking States for a huge step-up in their health spending.

Rajeev Ahuja, a development economist, was formerly with the Bill and Melinda Gates Foundation and the World Bank.

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