Need for robust primary healthcare system in Northeast India
Background and Rationale
A report by the World Health Organization (WHO) and the World Bank states that nearly 50 percent of the global population has no access to essential health services (World Health Organization, 2017). The situation is worsened as millions of households are pushed into poverty annually because they have to pay for healthcare out-of-pocket (OOP).
In India, roughly 40 million people are pushed into poverty every year because of having to fund their own health care (Nagarajan, 2018). Health-related impoverishment is a vicious cycle that is unfavorable especially for the rural population and urban poor in accessing essential and quality health services.
UHC and PHC
To overcome the healthcare challenges related to inequality and lack of access to essential health services for a majority of the global population, United Nations (UN) member states were tasked with realizing universal health coverage (UHC). UHC is a priority commitment within the Agenda for 2030 Sustainable Development Goals (SDGs).
In the achievement of UHC, the focus is on financial risk protection, access to quality essential health-care services, as well as access to safe, effective, quality and affordable essential medicines and vaccines for all.
The global conference on primary health care (PHC) hosted in Astana, Kazakhstan, in October 2018, renewed the core principles included in Alma Ata Declaration in 1978, emphasizing the essential role of PHC around the world. The Declaration of Astana focused on primary health care to ensure that everyone everywhere can achieve a good standard of health.
On 23 September 2019, the United Nations General Assembly (UNGA) held a high-level meeting (UN HLM) on universal health coverage. This meeting, held under the theme “Universal Health Coverage: Moving Together to Build a Healthier World,” identifies primary health care as the route to UHC. The UN HLM was the final opportunity before 2023 (the mid-point of the SDGs) to mobilize the highest political support to have the whole health agenda under the UHC umbrella.
At the UN HLM, member states including India were tasked with implementing UHC. In line with UHC key asks, the Indian government has a responsibility to ensure political leadership beyond health and to leave no one behind in the pursuit of equity in access to quality health services.
UHC further emphasizes the need to uphold the quality of care and create a strong and enabling regulatory and legal environment responsive to people’s needs. To meet UHC expectations, the Indian government must also strive to uphold the quality of care and make more and better health investments. Meeting UHC expectations is also dependent on the capacity to move together in establishing multi-stakeholder mechanisms for engaging the whole of society for a healthier world.
Key Concerns and Challenges in India’s Northeastern States
According to an article on worldatlas.com by Mattyasovszky (2019), India is the seventh-largest country in the world by area with a territory that stretches over 3.29 million square kilometers (Mattyasovszky, 2019). Thus, India has diversities in various aspects, including economic status, social structures, and geographical terrains.
Healthcare service provision in the nation varies from one state to another. For instance, populations in the northeast region of India are greatly affected as they lack adequate access to essential health services. The inadequate access to essential health services in the northeast region of India can be attributed to various factors, including poor connectivity and road networks, sparse population, hilly terrains, and communities having a limited means of livelihood.
In Northeast India, the average availability of health workers such as the total number of government allopathic doctors and the total number of registered nurses and midwives are at a minimum as compared to other states. For instance, in the region, the population that is served per hospital bed is 1061 persons (Hossain, 2015).
This might be considered satisfactory in line with the region’s low population. According to Hossain (2015), health indicators such as life expectancy at birth (LEB), the maternal mortality rate (MMR), and total fertility rate (TFR) are better than the national average but worse than the better-performing states such as Punjab and Kerala.
The three-tier healthcare system that India follows entails a sub-centre, Primary Health Care Centres (PHCs), and Community Health Centres (CHCs). (Bhattacharjee, 2020). A sub-centre often has an Auxillary Nurse Midwife (ANM) who works alongside a male health worker.
A PHC comprises of 6 sub-centres and often has between 4and 6 bends that help to address immediate and basic healthcare necessities. Community health centres are relatively large and have a sizeable health care team comprising of four doctors and a minimum of 21 paramedics (Bhattacharjee, 2020). These facilities are important for individuals seeking basic healthcare services before referrals to tertiary healthcare facilities are considered.
Inadequate access to essential healthcare services in the northeast region of India, which comprises of border-states such as Assam, Mizoram, Meghalaya, Manipur, Nagaland, Tripura, Sikkim, and Arunachal Pradesh, is an issue of concern and underlines the urgency of the need for a robust primary healthcare system in the region.
The issue of inadequate access to essential healthcare services points to the fact that India is far from achieving UHC goals as these goals emphasises access to basic and essential healthcare services.
UHC goals include improving coordination of health systems strengthening (HSS) efforts for UHC at the global level including synergies with related technical networks; strengthening multi-stakeholder policy dialogues and coordination of HSS efforts in countries; facilitating accountability for progress towards HSS and UHC that contributes to a more integrated approach to accountability for SDG3 (ensure healthy lives and promote well-being); and building political momentum around a shared global vision of HSS for UHC and advocating for sufficient, appropriate, and well-coordinated resource allocation to HSS.
UHC requires that the Government of India must ensure the right to health for all (Tikkanen et al., 2020). Every state in India, including those in the northeast, must provide free universal access to healthcare services.
The cost of providing universal healthcare delivered through a combination of public and private providers is estimated to be INR 1713 per capita per year in India, which amounts to 3.8 percent of GDP in India. Unfortunately, India is not meeting this given that the annual data released by the government in 2019 indicated that only 1.28 percent of GDP (2017-2018) was spent as public expenditure on health (Chandna, 2019). The figure was even lower in 2016-17 at 1.02 percent of the GDP.
These figures indicating India’s low public health expenditure on health underlines the need for improvement in this regard. The improvement will entail the establishment of a robust primary healthcare system to boost the chances of achieving UHC objectives.
The good news is that the government is taking steps towards improving the healthcare system. The government has come up with publicly financed health insurance. Essentially, citizens can access government health services under the tax-financed public system. A major initiative under the publicly financed health insurance is the Rashtriya Swasthya Bima Yojana (RSBY) that was initiated under the Ministry of Labour and Employment in 2008 to provide health insurance coverage to low-income families (Tikkanen et al., 2020).
A major milestone was the enrolment of 41.3 million families to RSBY in 2015-2016, signaling a 57 percent achievement of the set target. India’s Ayushman Bharat is another clear indication of a commitment to improving the healthcare system.
Ayushman Bharat is considered one of the world’s largest health insurance schemes. It was launched by the current government in 2018 and is on course for implementation (PTI, 2020). The scheme seeks to cover over 500 million beneficiaries while providing coverage of Rs 500,000 per family annually (PTI, 2020).
Ayushman Bharat seeks to improve access and quality of primary healthcare through strengthening 1, 50,000 sub-centres and primary health centres (PHCs) [transforming them to health and wellness centres (H and WC)] and improve access to secondary and tertiary care through a near-universal health insurance scheme (Lahariya, 2019). These efforts have been vital to revamping India's primary healthcare system at the national level.
Already, Ayushman Bharat program has been rolled out across India. In an annual report released by the National Health Authority (NHA), which runs the program, it was indicated that more than 10 crore e-cards (for health insurance) were issued and Rs 7,490 crore worth of treatments pre-authorized in just 365 days (Dhankhar, 2020). This figure amounts to slightly over Rs 16,000 per person, which is significantly lower than the Rs 5 lakh limit per family under the program (Dhankhar, 2020). Although the program has been instrumental in reducing people’s expenditure on health, the health expenditure burden has not been lifted.
Rather, the burden has been shifted to the shoulders of the government that is currently facing a big challenge in meeting the population’s healthcare needs, particularly in the northeast region.
Critical to the expansion of the primary health care system in India’s NE states is the development of public health infrastructure. The shortage of basic healthcare facilities in several states in the region is evident. For instance, Assam has a 50 percent shortage of Community Health Centres, though they are a critical component of the region’s primary healthcare system. In Tripura, there is a 17 percent shortage of Primary Health Centres (PHCs) (Bhattacharjee, 2020).
Additionally, there is a big shortage of skilled manpower in the entire northeast region including superiors, specialists, doctors, and female health workers (Bhattacharjee, 2020). The Northeast region of India has a supply gap of approximately 36,009 registered doctors (Bhattacharjee, 2020).
When it comes to the supply of trained nurses, there is a 66 percent gap. Thus, bridging the gaps of infrastructure and human resource needs are paramount before or simultaneously with the development of Health & Wellness Centres in the Northeast region for a robust primary health care system.
To further strengthen the primary healthcare system in North East India, there are several criteria to be fulfilled. For starters, care provided must be comprehensive, in that it addresses all health problems in all patients at all stages of life and be continuous over time (van Weel & Kidd, 2018).
Comprehensive care entails providing ongoing care of patients across healthcare settings such as hospitals, nursing homes, clinicians’ offices, schools, community sites, and homes (Institute of Medicine, 1994).
The government must strive to hire competent primary care clinicians who listen to patients, evaluate, make diagnoses, manage, and screen for other health problems. Critical aspects of Comprehensive healthcare to be taken care of are acute care, chronic care, prevention, and coordination of referrals.
Such comprehensive Care must be made accessible to everyone in the local community since many people in the Northeast currently lacks universal access to care. Accessibility refers to the ease with which a patient can initiate an interaction for any problem with a clinician. This can either be through phone or at a treatment location (Institute of Medicine, 1994). Already, India has a public insurance coverage plan to improve affordability and access.
However, this has not guaranteed affordable access to care, particularly in northeast India in local health settings where local clinicians are unwilling to serve individuals with this form of insurance coverage as there are delays or rejection of reimbursement claims.
To enhance accessibility to health care in the northeast, the Indian government should put in place integrated delivery systems that may establish policies regarding how patients can access clinicians for primary care and ensure secondary and tertiary referrals whenever needed.
It can also be enhanced through the emphasis and development of an emergency transport system from primary care, which is a key to access to all levels from an entry point to the highest point of appropriate care.
Efforts must be made to register patients with an individual provider or practice, which will allow care to be provided to an identified population of patients over time (van Weel & Kidd, 2018). Additionally, the relationship between patients and individual providers or practice is enhanced, and this is at the heart of the provision of primary care.
The primary goal in this regard is to ensure that every patient receives optimal care, whether he or she regularly seeks care or not.
As described above a robust three-tier primary health care system must be supported by a further ready access to a good tertiary care system and this can be achieved by (1) strengthening referral linkages from the Health & Wellness Centres including ambulances and (2) strengthening district hospitals to function as tertiary care.
As of today, the state is entirely dependent on medical colleges for tertiary care provision, and the potential of midway located District hospitals are untapped.
(Dr Priscilla C Ngaihte is advisor to Public Health Foundation of India. Views expressed are personal)