public health policy

In new health and wellness centres, India has a good plan for primary care – backed by little action

The budget announcement about these upgraded primary health facilities has been overshadowed by the National Health Protection Scheme.

In his budget speech Finance Minister Arun Jaitley called Health and Wellness Centres the foundation of India’s health system. Yet, discussion and analysis of the budget have largely ignored this provision, preferring instead to focus on the National Health Protection Scheme that was also announced. This despite the fact that the health and wellness centres are supposed to cater to at least twice the number of people that the NHPS is supposed to cover and that the government will have to spend more on these centres than on the NHPS.

The proposed centres are supposed to be the main points of contact for communities with the public health system and better versions of existing health sub-centres and primary health centres. The centres will provide primary, outpatient care and referral access to secondary and tertiary health care when needed.

The 1,50,000 lakh health and wellness centres as envisioned in the National Health Policy, 2017, Jaitley said, “will bring health care system closer to the homes of people. These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services. These centres will also provide free essential drugs and diagnostic services.”

This upgraded health center will have four essential features:

  • Services will not be limited as they are now to pregnancy care, immunisation and some communicable diseases that represent less than 10% of morbidity. A Health and Wellness Center will handle more than 70% of all outpatient care including non-communicable diseases and mental illnesses.
  • The role of the doctor and specialist will be extended from making a diagnosis and treatment plan to ensuring medication compliance for chronic illness and follow up care delivered close to home.
  • Each centre will have at least three full time health workers complemented by five community health workers, all of whom work are preferably recruited locally.
  • The centre will have a much wider range of free drugs and diagnostics, including many that need to be prescribed but can be made available  locally by the health workers.

This revamp of the primary health system is much needed. Millions of patients with chronic illness, often senior citizens, currently face the large monthly expenses and the drudgery of travelling to the nearest district hospital or medical college hospital to get a monthly dose of their medicines. As a result, compliance drops to less than 20% of desired levels. Patients, who should be able to manage diseases like hypertension and diabetes with minimal expense, develop life-threatening complications like strokes, heart attacks and kidney failures, which are expensive to treat.

Jaitley also said that the government was committing Rs 1,200 crore in this budget for this flagship programme and at the same time invited contributions from the private sector through corporate social responsibility initiatives and philanthropic institutions in adopting these centres.

Not a promising start

Estimates by the ministry of health and family welfare show that it will cost about Rs 17 lakh to set up and run a health and wellness centre in the first year and about Rs 7.5 lakhs per year in subsequent years. This will be an additional cost to what is already being spent on running existing health sub-centres and does does not include the cost of medicines, diagnostics, information systems and referral consultations. If we estimate that running a health and wellness centre will cost about Rs 10 lakh per year, the government will have to spend Rs 15,000 crore per year to run 1,50,000 such centres. If we take the more reasonable estimate – including costs of medicines, diagnostics and information systems – of Rs 20 lakh per year per centre, then the annual spend on the scheme will be Rs 30,000 crore.

The health and wellness centres are supposed to cater to all people across the country. If we assume the top income quintile can afford and so is more likely to seek healthcare at private medical facilities and leave them out of calculations, the centres will have to serve some 104 crore people. The Rs 1,200 crore that Jaitley has committed to the scheme will pay to set up about 10,000 of centres covering between three crore and five crore people – 5% of the target population.

What is curious is that while this paltry amount is not specified as a separate amount for health and wellness centres in the budget details. The government may have clubbed it under the outlay for the National Health Mission but there has been a reduction in fund allocation to the NHM. This means that states will have to divert some essential healthcare expenditure to pay for these proposed centres. This is not a promising start for what the finance minister calls the foundation of India’s health system.

A primary health centre in  Jalandhar. (Photo: Hindustan Times)
A primary health centre in Jalandhar. (Photo: Hindustan Times)

Even though the NHPS has got more attention since the budget, by design it covers only costs of secondary and tertiary care. More than 70% of out-of-pocket health expenditure is on outpatient care, much of which can be shifted to the primary level. The concept of health and wellness centres addresses the current problems of access and financial protection for outpatient care. A recently released pilot study from Tamil Nadu of some 67 health centres upgraded to Health and Wellness Centres shows that out-of-pocket expenditure has been reduced dramatically and has become almost negligible. At the same time people’s access and utilisation of healthcare has greatly improved within just one year.

Lessons from abroad

The National Health Service in the United Kingdom has been a pioneer in primary health care. Every household is registered with a “general practice” as it is called which has about five general practitioners, two to three nurses and six support staff. . A typical practice team caters to about 6,000 patients. These centres work closely with an even broader, often co-located primary health care team that is employed directly by the NHS that may have district nurses providing home nursing care, health visitors who provide child care as well as midwives, psychiatric nurses and allied health professionals. But the UK also has a high GDP per capita and spends 10% of its GDP on health, of which close to 80% is public health expenditure.

Brazil achieves similar results through Family Health Teams that provide preventive and basic healthcare using multidisciplinary teams of a physician, a nurse, and about six community health workers. There may also be a co-located dental team. Each group of four or five health teams also has other professionals like psychologists, community pharmacists and physiotherapists. Each core team is assigned a geographic area covering 3,000 to 4,000 people, with a maximum of 150 families per community health worker, or about 4,000 population per family health team. Brazil spends about 8% of its GDP on healthcare and its public health expenditure is about 4.5% of the GDP.

Thailand achieves a similar health outcome using its primary health centers which function under the leadership of a district hospital. Each of its primary health centers has a coverage of about 3,000 to 4,000 people and consists of a team of about five nurses or paramedical workers. Thailand’s total health expenditure is about 4.4% of GDP and its public health expenditure is 3.3% of the GDP, which is a level of government health expenditure that India can achieve. Cuba, Costa Rica, Iran and Sri Lanka have similar strategies and results with cashless or highly subsidised services.

India’s health and wellness centres borrows from these international examples of more comprehensive primary healthcare. India’s health and wellness centres are currently designed to cater to 3,000 to 5,000 people with three nurses or paramedical workers. But so far the health ministry has been unable to mobilise either the resources or the political will required to take it to scale. There may be other politically-influenced distractions, like turning these centres into centres to promote yoga or other wellness practices.

Low impact

One reason why there has been little excitement about health and wellness centres might be the limited role of markets that have so far shunned preventive healthcare, which necessarily has to be provided by public systems. So even though the finance minister has asked for private sector and philanthropic adoption of these centres, such participation is unlikely to happen.

Yet, having a nationwide network of health and wellness centres within three to five years is a feasible goal. To achieve that, we must first shift our single-minded focus on health insurance schemes and pay attention to this primary healthcare proposal.

The writer teaches at school of health systems studies, TISS.

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