How India’s Primary Health Centres Can Be Nursed Back To Health

Primary health centres (PHCs) serve as the principal, and initial, port of call for people seeking provider help in matters relating to primary care in India. The National Portal of India describes it as the cornerstone of rural healthcare.

According to the National Health Mission constituted under the Ministry of Health and Family Welfare (MHFW) of the central government, each PHC is supposed to serve up to 30,000 people in "general areas" and 20,000 people in difficult/tribal and hilly areas. Public health facilities come in three forms: sub-centres (serving up to 5,000 people), PHCs and community health centres (CHCs, serving up to 120,000 people).

As of March 2016, according to MHFW, there were about 155,000 sub-centres, 25,300 PHCs and 5,500 CHCs. The shortfall in PHCs was estimated to be about 22 per cent. Over 9,000 PHCs were reportedly 24x7. They are established and maintained by individual state governments under the basic minimum needs and minimum services programme and serve as referral units for six sub-centres. PHCs are, well, primary and supposed to cater to preventive care needs and staffed with a doctor, one or more nurses, attendants and minimal equipment including a small lab and pharmacy. They undertake "curative, preventive, primitive, and family welfare services".

The performance of PHCs, in general, has been dismal, and this has been brought out by the erstwhile Planning Commission's evaluation study in 2001. The study identified lack of facilities, under-utilised facilities, absence of lady doctors in most centres, lack of utilisation of facilities by beneficiaries owing to inadequate resource availability, mis-match and non-availability of complementary services (especially in obstetric and gynecological expertise) and general dissatisfaction of beneficiaries with the functioning of the centres.

An untenable position

The government spends approximately Rs 4,000,000 on average on a PHC in the rural areas every year. The government's own reports confirm that this money has not been well-spent, based purely on the quality of deliverables and outcomes achieved. This tells upon other macro healthcare indices: infant and maternal mortality, under-five (U-5) mortality, infectious disease incidence, life expectancy and so on.

A new index developed by an international collaboration on the Global Burden of Disease presented at the United Nations General Assembly in 2016 to assess achievement on various health indices and published online in The Lancet ranked India 143 out of 188 countries – six positions ahead of Pakistan but way behind Sri Lanka (79), China (92), and Iraq (128). The index measured a nation’s “sustainable development goal” (SDG) on a scale of zero to 100, Iceland topping the list with a score of 85 and the Central African Republic at the bottom with a score of 20. India scored 42. The index comprised a mix of infectious diseases and factors such as malaria, U-5 mortality and safe hygiene practices, to name a few. Clearly something is amiss and most fingers point to inadequate, inefficient, unresponsive and mis-managed health delivery by state resources on the ground. PHCs take the brunt of the blame.

With the emergence of chronic disease, or non-communicable disease (NCDs), in epidemic form, however, PHCs assume significantly greater importance. Study after study now concludes that chronic disease is no longer a "rich person's disease" – it affects the poor as much as the rich, the rural dweller as much as the urban, and the illiterate as much as the educated. More importantly, it has been striking at a younger age in the developing world compared to the developed. Cases of cardiovascular disease, as also incidence of cancer and pre-diabetes, among people in their 30s are no longer a rarity in India.

In this new reality, PHCs have to be redesigned with new responsibilities and more effective and efficient ways of delivery. So far, they have been constituted on a government model that has revealed several weaknesses, accountability being among the most important. Moreover, inadequate funding, staffing and facilities have hindered effective response at the community level. Clearly, while the problems mount, PHCs are finding themselves more and more on the outside, with increasing numbers of rural folk opting out while urban residents have already made their choice with private practitioners and clinics. Four broad areas of focus in the contemporary context should include injury, woman and child, infectious diseases and NCDs.

Individual physicians and private clinics, while they have taken on the role of primary care, are not equipped to deal with NCDs that require systems and processes for monitoring, early detection and lifelong management once a person has been identified with a disease. These diseases are often asymptomatic and dormant for a long time when they become acute and individuals get admitted to urban tertiary care hospitals. From that time onwards, NCDs require specialist attention with the result that those with a condition are burdened with disruption to work, family aggravation and major expense, most of it out-of-pocket. According to the World Health Organization (WHO), NCDs are today the leading cause of morbidity and mortality in the world and the under-appreciated cause of poverty. Hence, they call for very different ways of clinical attention compared to acute conditions – efficient data capture, data portability and data sharing across disciplines – from the GP to the specialist and preferably with an integrated approach.

Moreover, there is the issue of urbanisation. It is estimated that about 40 per cent of India's population will live in urban areas by 2025, of which the poor would comprise one-fourth. The urban poor indicators of health, contrary to what one might expect, are in many ways worse than in rural areas: 60 per cent do not receive immunisation, 47 per cent of urban poor children are under-weight (45 per cent in rural areas), 59 per cent of women in the 15-49 age group are anemic (57 per cent), and poor child survival rate of 1.3 children dying before the age of five. The National Urban Health Mission would have to make a serious study of the deficiencies of the National Rural Health Mission (NRHM) and adapt to the particular complexities of urban environments.

Needed: radical model redesign

The several problems, most of them already identified and known, call for a radical makeover in how PHCs are set up, organised, managed, incentivised and run. While the more affluent southern states (and a couple in the north) have sufficiently well-run systems (but with widely varying quality intra-state), the bulk of the country is bereft of any meaningful primary care that addresses current problems and is prepared for those in the near future. The persistence of poor healthcare metrics for the nation as a whole emanates from this weak link in the chain. PHCs, in fact, could do more than just attend to injury, women and child health and infectious diseases that they now (inefficiently) perform. They could be the basis for a completely re-thought and re-worked integrated community care model that address these, as also that of NCDs that now stalk the nation. But to perform this role they have to do it differently, involving both technology and design of incentives.

Below, we discuss ideas that could dramatically infuse new energy and focus to PHCs and make them truly the pillars of Indian healthcare.

1. Let PHCs become entrepreneurial startups

Currently, PHCs (as also sub-centres and CHCs) are under the domain of the Ministry of Health in the various states. Broadly, the central government frames the policies and disburses funds to the states, and the state governments manage the affairs. PHCs are essentially government delivery instruments, and all staff automatically employees of the state. While new models are being tried out in some states – Karnataka and Rajasthan, for instance, are experimenting with a few PHCs being outsourced to non-profit foundations – state ownership and administration largely describes the model accurately. It hasn't worked well in half a century and expecting it would improve in the future is wishful thinking.

Instead, each PHC could become a “startup venture” and a general practitioner (GP) or group of GPs given the responsibility to turn it into a successful practice. The government, under an appropriate regulatory body, could define the fee for various services and required equipment, facilitate easy bank loans for the GP entrepreneur, mandate a revenue sharing arrangement that rewards the entrepreneur-doctor, tax rebates and healthy competition. If the GP-run individual PHC turns out very good performance figures (in terms of consumer engagement, patient growth, clinical encounter and outcomes howsoever defined), they should be allowed to expand by absorbing or taking over other PHCs, up to some maximum number, together with a mechanism to shrink if performance slips.

The critical elements in this model would be regulation, incentives, digitisation of consumer engagements, and care quality and satisfaction. Safeguards could be built into the design that, for example, prevent attending physicians from calling for superfluous tests and diverting patients to an outside practice. Better incentive design itself could be a motivation for ethical PHC practices, and innovations in practice management could institute superior internal controls and reporting. These concepts should form the foundation for redesigned PHCs.

2. Involve GPs and give them the opportunity

India graduates about 55,000 doctors every year, but severe shortages persist in PHCs (estimated at over 3,000 GPs). Five problems confront healthcare in every country in the world:

- Too many specialists concentrated in the cities and too few GPs in areas that matter

- Medical education tends to focus around specialties with increasing sub-specialty training in practice

- While primary care is critically important from a public health perspective, it is unglamorous, accorded little respect and discriminated against in compensation

- Issues of accessibility, availability, affordability and timeliness are best addressed at the primary care level that specialists are ill-trained for

- Available GPs are under-utilised, dispirited, severely underpaid, and only too willing to change careers to allied areas where they are paid better (such as back-end medical coding for business process outsourcing companies servicing overseas hospitals, emigrating to jobs in the Middle East and the United Kingdom's National Health Service, pursuing post-graduate studies where they become specialists, become hospital administrators and so on).

Most of these issues are addressable in the Indian context with the proposed model that would simultaneously solve for both the primary care (patient) as well as GP (physician) interests. Any idea needs to address the above and make it credible, respectable and rewarding while affording a superior patient experience.

3. Embed "connected health" in every PHC

The newly announced regulatory agency for digital health – the National e-Health Authority (NeHA) – should be leveraged and deeply embedded within the new model of PHCs run by entrepreneurial GPs. However, NeHA itself has to be designed in a way that takes forward the idea of enabling super-easy consumer engagement and a positive experience with doctors and not make it a challenge for them to solve a health problem.

We do not know the contours of the new agency’s responsibility, but if it is built on lines similar to the "India Stack", now falling into place in the financial sector under the aegis of the National Payments Corporation of India (NPCI) in relation to standards, protocols, API-based open data access, certification, national switch, portability, ownership and citizen rights, then there is no reason why a PHC cannot be plugged into something similar at NeHA and solve issues such as:

- Identity/authentication and record

- Trackability (of visitations, PHC and doctor identity, date and time), capture complaints and conditions, enabling easier diagnosis based on patterns, correlations, heuristics and artificial intelligence-guided treatment modality

- Focus on indicators of clinical outcomes that are made available real-time to the GP in individual and condition-specific dashboards

- Institute positive clinical outcome-based incentives and performance reward to GPs

- Replace free or low-cost services with fee-rated services by replicating the residential cooking gas model of direct benefit transfers (DBT) that entails minimal, listed, payment for services by patients at the points of presence from government healthcare subsidy credits directly into consumer bank accounts earmarked for the purpose.

- Health data store and portability

- Consumer satisfaction that could be assessed by means of ratings upon end of every patient engagement in a form similar to what Uber has for its drivers

Such a possibility would elevate a simple PHC with its current reactive, and indifferent, attendance to local health concerns to proactive, frontline "forward forces" in detection and defence against disease emergence by means of heat maps that give forewarning – whether infectious or chronic – and to respond with precision and urgency. If done in a manner that fully recognises and incorporates the several frustrations of both the consumer and the practicing clinician,, this has the potential to transform PHCs and ensure quality care is delivered at an affordable cost. Furthermore, the GP could be incentivised in ways that reward quality of service and consumer satisfaction.

Aligning with National Health Policy

The central government is reported to have approved a National Health Policy to provide "assured health services" to all in the country. According to news reports, the policy increases the gambit of sectors covered in the PHC level and envisages a comprehensive approach. The ministry noted that heretofore, PHCs were only for immunisation, anti-natal check-ups and others. But what is a major policy shift is that now it will also include screening non-communicable diseases and a whole lot of other aspects. NCDs already account for the bulk of disease burden in India and will only increase in the decades ahead.

In all such matters of public policy, half the battle is won when the government recognises imminent threats and comes up with clearheaded ideas on how to tackle them. What then remains is efficient execution, and that is where reliance on tired old methods and solutions would benefit from a complete overhaul. A different business model would do a world of good.

The solution?

Many challenges confront such a radical idea. Healthcare in India is a "state subject", which means the central government's responsibilities in how healthcare is delivered are limited. It creates nation-level policies and the regulatory mechanisms and disburses funds. What happens after is largely a function of the maturity and state of development in each state. A radical solution for redesign of PHCs should address the following:

- Regulation and legislative approval to reform and reorganise PHCs. This may well be seen as "privatisation", a red herring to politicians. However, state governments are increasingly receptive to "entrepreneurship" with its connotations of individual passion, persistence, innovation and employment generation. PHCs in the hands of individual GP entrepreneurs could be seen as a better alternative to large corporate ownership that attracts opposition while utilising GPs who might otherwise be lost. But this is a challenge nonetheless.

- An active plan that combines central and state agencies to push NeHA's reach into every PHC. This would detail the expected benefits, monitoring mechanisms, measurement of outcomes and response to citizen ratings at the individual PHC level. Fortunately, this would not be very much a greenfield exercise as India has recent experience in executing and implementing a large-scale digital model of engagement in the financial services industry that encompasses authentication, citizen services (DBT for cooking gas, rural employment, public distribution systems), payments and emerging secure document management. These very same technology architectures, expertise and experience could not only be suitably fine-tuned and leveraged in healthcare, but would serve to extend the usefulness of the investment in the realm of public health infrastructure. It would also take India closer towards a digitised society that makes citizen welfare an essential and core part of it.

- A coordinated, well thought-out plan to promote GP entrepreneurship. The aim would be to foster ownership for individual PHCs and institute accountability. These should, minimally, include a qualification and assessment of GP applicants to manage PHCs, fast approvals that seek to align GP applicants to geographically distributed PHCs, single-window clearance that brings together applicant approvals to bank loan approvals for defined capex and working capital, well-defined clinical standards and metrics for delivery and outcomes, institutional regulatory mechanisms for quarterly health quality assessments and audits of individual PHCs, clearly defined fee structures for various clinical/lab/pharmacy services that automatically debit consumer health subsidy amounts to the PHC on engagement, defined revenue share in the PHC's revenues, mandatory continuing education for GPs, mechanisms for exit or removal in case of mismanagement or malfeasance and mandatory external financial audit.

- Incorporate and promote smartphone app-based teleconsultations. Remove face-to-face visit constraints and scale, and separate engagement metrics for offline and online physician-consumer interactions.

Most importantly, the success of any such endeavour would rest on three principles:

First, the model fine-tunes and embeds behavioural psychology, wherein both consumers and clinicians best respond to incentives that reward good health – the PHC for ensuring prompt, efficient and effective care delivery and the patient for ensuring they maintain it. Incentives need not necessarily involve monetary compensation, and this is where innovation is called for in inducing behaviour modifications.

Second, a primary yardstick of clinical outcomes (or “delivery excellence”) that is clearly defined by which performance is measured, monitored, improvements made and local innovations disseminated across the system.

Third, a secondary yardstick could involve financial metrics that surface necessary improvements in cost structure and efficient utilisation of resources.

These three principles could be undertaken as part of a pilot programme and taken up as an experiment involving a sample of PHCs in a random distribution of districts in the country.

There is no reason why India has to suffer the effects of bad planning, misallocation, inadequate budgetary support and inferior execution in public health. A startup model that fosters physician independence and rewards excellence in clinical practice and outcomes is better positioned to address consumer issues while building efficiency and optimal performance in the system. This is likely to be far superior to any government-run model. Recent trends in modern governance and technology hold great promise to envision replacement of the old with a new paradigm.

This article is an abridged version of a blog originally published on LinkedIn on 16 March 2017.