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Resource centre on India's rural distress
 
 

The lack of primary healthcare in India-Dr. Zeena Johar & Dr. Nachiket Mor
-The Economic Times

India has some of the best quaternary and tertiary care in the world and is gradually acquiring a name for itself even in the field of 'medical tourism'. Secondary care is still a significant challenge, but even in several smaller towns and district headquarters, there is a growing supply of maternity homes and multi-speciality secondary care facilities.

At all of these levels of care, given the large disease burden and propensity of people to directly approach these facilities even for relatively routine treatments, while availability of capital can sometimes be a barrier, the financial viability is most often not in question. It is our expectation, therefore, that supply-side problems for higher levels of care could, over time, get resolved even in the absence of concerted policy action.

In terms of aggregate supply of qualified physicians, there is indeed a problem, but given the fact that physicians trained in alternate systems of medicine are available in sufficient numbers and have legal licences to practice allopathic medicine, it would appear that a modest amount of training effort directed at them would be able to address this supply constraint for primary care. For higher levels of care, where formal allopathic training would be essential, the number of such physicians may prove to be adequate.

However, in our view, there are two challenges that need a significant amount of effort, and those are in the related domains of primary care and the integration of primary care with higher levels of care. Spain and UK in the developed world and Thailand, Brazil and Mexico in the developing world are seen to be good models of healthcare delivery.

In all of these systems, primary care forms the anchor around which the entire system is built and there is a high level of integration between various levels of care with strong gate-keeping and patient management functions being performed by the primary healthcare providers.

Even for India, the High Level Expert Group on Universal Healthcare appointed by the government of India, which recently submitted its report, has stressed these two ideas and has gone on to recommend that as much as 70% of the total healthcare budget needs to be reserved for primary care.

The actual situation in this regard on the ground in India is very grim. In most parts of the country, formal primary care is virtually non-existent. Within the urban context, there is a moderate amount of formal primary care available in the form of general practitioners, ophthalmologists, dentists, etc. There are also outpatient departments of secondary and tertiary care in urban hospitals that offer primary care services.

However, the care is fragmented and, for the most part, comprises management of visible symptoms rather than the overall health of the individual. In rural India, the situation is much worse with neither the private sector nor the government providing this level of care.

So, most rural residents either do not seek any form of primary care or visit local 'medicine men'. These 'doctors' offer any number of rational and irrational cures, several of which cost a great deal of money for little benefit, and a few with strong potential for actual harm.

The government does have a guideline for having a local health centre at a 5,000 population level (referred to as a sub-centre) but the centre does not have a physician as part of the design and, therefore, cannot prescribe any scheduled drugs, operates with very limited hours, and currently restricts its attention largely to prenatal and antenatal care.

The formally-designated governmental Primary Healthcare Centre is at a 25,000 population level and does have a physician as a part of the design, but is too far for most people and receives such a large volume of patients that the lone physician is reduced to spending anywhere between 10 seconds to a minute per patient. So, even serious illnesses often remain undiagnosed for long and many patients end up at urban secondary and tertiary care centres, often at a very late stage.

It is our belief that the kind of primary care needed will not emerge spontaneously in the absence of a strong implementation effort by the government or a concerted effort by a far-sighted corporate sector. These reasons include the tendency of even educated individuals to postpone seeking care until seriously ill, resulting in high price elasticity for primary care services.

This makes it hard to build financially-sustainable and rational models of primary healthcare unless one has full control over the entire value chain and can direct the patient appropriately using strong gate-keeping functions.

(Dr Z Johar is president, andDr N Mor is a non-executive member of the board, at the IKP Centre for Technologiesin Public Health)