Building a Comprehensive Healthcare System
Building a Comprehensive Healthcare System
- Medically, since the most important drivers of infant, child, and maternal mortality are haemorrhage, sepsis, abortion-related complications and hypertensive disorders.
- It is clear that it is no longer adequate for a health system to focus on preventive-promotive messages and limited facility-based treatment options.
- Instead, at the community level, there needs to be clinic-based obstetric and emergency care on offer, and, within a reasonable travel distance, hospital-based emergency care.
Condition of States
- Recent data for infant mortality rate (IMR) and maternal mortality rate (MMR) shows that higher availability of more advanced medical care at proximate hospitals in, for example, Kerala and Tamil Nadu, is indeed associated with much better MMR and IMR outcomes.
- Equally wealthy States such as Himachal Pradesh, which do not have these advanced facilities at proximate locations, are not able to show similar rates of improvement despite spending more money per capita on healthcare.
HEALTH AND WELLNESS CENTRE
- Recognising this issue, the Indian government has recently mooted the concept of a health and wellness centre (HWC) that is intended to be more comprehensive rather than merely connoting “first contact care or symptomatic treatment for simple illness with some elements of care for pregnancy and immunisation included”.
- Comprehensibility is required for gainful employment and sustainability.
- And, if indeed the HWCs (the erstwhile sub-centres) are able to address all of the necessary MCH conditions, then it becomes possible for the next level centre to provide a much broader range of care upon referral by the HWC.
The obstacles are
- Absence of political commitment and hence lack of funds.
- Low Quality services and absenteeism problems of Doctors and Nurses.’
- Lack of evaluation and Accountability of doctors, nurses and health care centres.
- Indian (MCH-focussed) health system is currently able to cope only with conditions that account for fewer than 25 per cent of the Years of Life Lost (YLL-years of life lost due to premature deaths).
- Even in high-fertility States such as Bihar, in a typical year, fewer than 20 per cent of the households are likely to have maternity-related needs.
Problems of Health Systems in India
- They were designed as MCH-only systems; they have become chronically under-resourced and have now built a very high- cost but low-performance culture and a concomitant reputation.
- Instead of rescuing this system, the executives prefer to put additional investments into fragmented and “cheap” in-patient insurance and ambulance schemes that are operated by the private sector but are funded by the government.
- It leads to fragmentation of the health system, with a low-quality, skeletal MCH-focussed government-run primary care and secondary care system. There is also a separate, private sector-owned secondary and tertiary care system with very high variations in the levels of quality, which is accessed by low-income families through government-sponsored insurance programmes and by everybody else using out-of-pocket payments.
- This prevents the evolution of both an integrated government health system or a privately run managed care system.
- For various good reasons, 68 countries, including low income and middle income countries, have chosen to use health-specific taxation such as mandatory payroll deduction.
- For countries such as India and China, which also have a large informal sector, since mandatory payroll deduction is not an available option for a large segment of the population, the direct sale of healthcare packages or insurance becomes additionally necessary.
- Families above poverty line have the financial ability to pre-pay for healthcare services because it is not their average out-of-pocket expenditure that is their problem, but their inability to obtain proper care when needed and the high variability of actual expenditures. Their pre-payment (by, for example, requiring the purchase of a comprehensive family health cover along with auto-insurance for all vehicles, including two wheelers), requires an integrated delivery system which is going to need a much broader health system and one that performs at a much higher level than it currently does.
- For the States, the larger availability of untied funds from the Centre presents a historic opportunity to design health systems that far more closely reflect their own objective ground realities.
- While centrally sponsored health schemes have offered a number of benefits, they also came with the associated baggage of standardised design.
- Bihar, for example, continues to battle with high levels of IMR and MMR and a high level of poverty.
- Tamil Nadu and Kerala have brought those rates under control but, unlike Bihar, are seeing a climbing suicide mortality rate, particularly amongst their 15-25 year olds.
- Himachal Pradesh, which has a much smaller and significantly wealthier population and over five times higher per capita income, has very similar IMR and MMR numbers to Bihar, combined with a high accident mortality rate.
Building comprehensive healthcare systems which reflect the realities of each State will not only yield strong benefits on problems such as IMR and MMR but will also, over time, help build health systems that respond to a much a wider set of concerns. Narrowly focussed health systems on the other hand risk falling short not only on their goals but also make it difficult, if not impossible, to build broader health systems for the future.