By Dr. Swati Mahajan and Akshat Garg, AVPN
The pandemic has had a silver lining – it reminded every stakeholder of the relevance of resilient, reliable, and professional healthcare, for all. While health for all has long been an aspiration goal for the Government of India and civil society, progress has often been slow and unsatisfactory.
One key challenge is the metric of success that is used to evaluate healthcare. Most common metrics include the number of beds per million, number of doctors and number of beneficiaries registered under National health services. These further get evaluated against outputs such as new capacity created or outcomes such as Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) improvement.
However, given the regional bias of access, it is hard to draw direct causality between state level numbers and village level access. The Ayushman Bharat Mission, a revamped public health approach by the Government of India is now focusing on holistic health and wellness centres. For instance, to ensure delivery of Comprehensive Primary Health Care (CPHC) services, existing Sub Centres are being converted to Health and Wellness Centres, with the principle being “time to care” to be no more than 30 minutes.
A similar approach is also being undertaken for the existing Primary Health Centres. Along with a care “hub”, spokes such as outreach services, mobile medical units, camps, and community-based care are also being set up. The key principle should be a seamless continuum of care that ensures the principles of equity, universality, and no financial hardship.
Thus, an argument for a more qualitative and holistic “wellness” centric approach to health care seems to be developing. This approach looks at ease of accessibility, affordability, and availability. These factors can include aspects like frequency of visits to healthcare centres, out of pocket expenditure, distance, time and costs to access medical services and assurance of medical aid at the time of need.
Given that these initiatives include regional variations of resources, access and preferences, and the existing policy focus is on CPHC at PHC and Sub-Centre level, a “Models of Success” approach is suggested. In this approach, adopted HWC’s are upgraded and modified to meet both quantitative targets (number of beds, staff, patients served) and qualitative targets (time to care, patient satisfaction, single window registrations).
The rationale for bringing in qualitative measures is based on the theory of compliance and psychological barriers to entry, and a shift from outputs to outcomes approach. For instance, the frequency of healthcare access can indicate both the nature of illnesses frequently encountered and the existing capacity available at the Primary Health Centre (PHC) level. With an existing JAM (Jan Dhan, Aadhar and Mobile) digitization infrastructure, this tracking is implementable.
Further, often the cultural habits and lifestyles, local preferences and endogamous nature of village level communities, results in the prevalence of certain medical issues in certain areas. While this data is available at the state level through the India State-Level Disease Burden Initiative by the Indian Council of Medical Research, Public Health Foundation of India and Institute for Health Metrics and Evaluation, more granular data needs to be developed. This targeted approach can help solve existing resource constraints by providing high priority skills and diagnostic tools at the community level, based on their specific needs.
There is also an administrative benefit of this “Models of Success” approach. Regional models of success invariably create healthy competition among districts. This helps break the administrative inertia and fosters ground for innovation and experimentation.
One example that came to light during Covid-19 was that of Bhosi Village, Nanded, Maharashtra, India, where villagers and local leaders worked together to contain the virus. Similar efforts can be made in areas of telemedicine, ideally linking the primary level Health and Wellness Centres (HWCs) equipped with essential diagnostic tools to Super-specialty hospitals across the country. This presents an opportunity for democratizing healthcare access in India.
Secondly, the Ease of Access Approach changes the way service is assessed in India. By making the experience of the patient an active part of the evaluation mechanism, we create a rights-based approach to public services. This is largely missing in the output-based approach of assessment. Gram Panchayats too have a critical role to play. Social welfare, including welfare of disabled, family welfare, women and child development and Health and sanitation including hospitals, primary health centres and dispensaries, fall within the domain of Gram Panchayats (Article 243G, 11th schedule, 73rd Amendment to the Constitution of India, 1992) and thus enjoy Constitutional protection.
Initial resistance from State and National level governments and bureaucracies, often due to additional compliance, subjectiveness, increased accountability and associated additional costs is understandable. Further, the subjective nature of evaluation provides greater administrative and political risks.
The private, nonprofits sector, however, is well suited to undertake this, in partnership with district level administration. The conception of Comprehensive Primary Health Care (CPHC) provides an opportunity for more public-private partnerships due to the intersection of both scale of operations and healthcare expertise. Private capital, non-profit implementation and evaluation expertise and administrative support, can create these low cost-high impact centers by upgrading the existing infrastructure in the short to medium term. Further, regular ground level monitoring and evaluation mechanisms can be stipulated, allowing funders to constantly monitor the impact of their investors.
Healthcare should be simple, accessible, and respectful. The “Models of Success” approach has the potential to solve some of the biggest challenges that healthcare implementation faces in India. Over the long term, this can empower the entire value chain – converging with national skill missions building technical and medical capacity to service the center at the community level itself. As India copes with the aftermath of the pandemic that revealed the vulnerabilities of our healthcare system, a decentralized, PHC level, service centric approach can allow us to “Build Back Better” (Sendai framework, 2015).
Views of the author are personal and do not necessarily represent the website’s views.
Dr. Swati Mahajan is a medical doctor, public health professional, and a passionate leader striving towards Health for All. Dr. Swati has been with Jhpiego for over seven years and in her current role, she is currently the Chief of Party for USAID funded NISHTHA project and national team leads for comprehensive primary healthcare for Jhpiego where she leads a team working across 14 states to provide technical assistance for the MoHFW’s Ayushman Bharat Health and Wellness Centers programme. She is a member of the task force on Role of Multipurpose Health workers in Primary Healthcare, taskforce for Community Health Officer mentoring, NITI Aayog-led a working group on raising the profile of Nursing Personnel in India, and Technical Resource Group for National Urban Health Mission.
Akshat Garg is a Volunteer Associate with AVPN’s Knowledge & Insights Team. He is currently pursuing his Master’s in Public Policy with Lee Kuan Yew School of Public Policy as a Li Ka Shin Scholar. Over the last half-decade, Akshat has worked in complex sectors such as public health, road safety, and skill development. He is currently working with AVPN to better understand the opportunities for social capital in India and help forge Public-Private Partnerships.