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Context: The pandemic experience has shown that India needs to make public health a central focus. Covid has also shifted the policy dialogue from health budgets and medical colleges towards much-needed and badly-delayed institutional reform.
It is heartening to note that the Ministry of Health has issued guidelines to states to establish a public health cadre.
It is time our political systems listen to people and take care of their everyday needs, instead of going for easy options like privatisation, commodification and medicalisation of healthcare.
Why India’s three-tiered subcentre model has failed?
Less than 10% of the health facilities below the district level can attain the grossly minimal Indian public health standards. Clearly, the three-tier model of subcentres with paramedics, primary health centres with MBBS doctors and community health centres (CHC) with four to six specialists, has failed.
Reasons:
The model’s weakness is the absence of an accountability framework. The facilities are designed to be passive — treating those seeking care.
What needs to be done?
Like in Brazil, we need Family Health Teams (FHT) accountable for the health and wellbeing of a dedicated population, say 2,000 families.
– The FHTs must consist of a doctor with a diploma in family medicine and a dozen trained personnel to reflect the skill base required for the 12 guaranteed services under the Ayushman Bharat scheme — midwives, public health nurses, other paramedics, health workers and community workers.
A baseline survey of these families will provide information about those needing attention — the elderly, diabetics, hypertensives, handicapped, pregnant women, infants, and those needing mental or physiotherapy services.
The team ensures a continuum of care by taking the family as a unit and ensuring its well-being over a period. Their work should be closely monitored, and the personnel should be given outcome-linked monetary and non-monetary incentives.
Such a system of primary care will need to work under the close supervision of a CHC manned by specialists in family medicine.
Creation of public health cadre: There must be a public health cadre manning the posts at the PHC and CHCs consisting of sub-specialists in family medicine, public health and public health management.
– Likewise, among nurses, the cadre should comprise two distinct sets of personnel — public health nurses (not ANMs promoted based on seniority) and nurse midwives capable of independently doing all clinical functions for handling pregnancies and women’s health issues except surgical interventions.
India needs to move beyond the doctor-led system and paramedicalise several functions. Instead of “wasting” gynaecologists in CHCs, when there is an overall shortage of them, midwives (nurses with a BSc degree and two years of training in midwifery) can provide equally good services except surgical, and can be positioned in all CHCs and PHCs.
Likewise, lay counselors for mental health, physiotherapists and public health nurses are critically required for addressing the multiple needs of primary health care at the family and community levels.
This needs to be acknowledged, and such trained persons appropriately positioned based on patient load and disease burden.
Way forward
A transformative health system will require a comprehensive review of the existing training institutions, standardising curricula and the qualifying criteria.
Faculty reviews are required to make the training inspirational and not dull and repetitive, as it is currently.
Spending on pre-service and in-service training needs to increase from the current level of about 1%.
Source: This post is based on the article “K. Sujatha Rao writes: Healthcare in India is ailing. Here is how to fix it” published in The Indian Express on 9th June 22.
Agree on the need for institutional reform. Perhaps more important factor is devolution of appropriate responsibilities to a working level officers with an effective guidance and supervision at the CHC level.
While we need to have specialist training and creation of public health cadre to attract the best talents manning the posts at the PHC and CHCs consisting of sub-specialists in family medicine, public health and public health management etc. the units usually become an island, they try to erect bureaucracy and barriers; our experience tell us that a single primary reason for failure of any large organisation is an effective lack of coordination among the specialist and service delivery units.
The CHC manned by specialists in family medicine must have the authority to resolve inter and intra unit issues on the spot and implement the most effective solution without much delay or procrastination. If I were to be manning such a CHC I will devolve appropriate responsibilities and encourage all employees not just come up with issues and barriers but also suggest options for overcoming impediments to a timely and effective service delivery.