In February 2017, the government of Tamil Nadu launched a pilot project to see if it could strengthen health sub-centres in the state and to gauge what impact it would have on the delivery of primary health services. An evaluation of the project a year later shows that simple interventions like ensuring basic infrastructure, medicines and manpower at the centres – the first points of contact of the public health system – make a large difference in patients accessing public health facilities and in reducing their expenditure on healthcare.

This project and its outcome are especially significant at this time when the central government is planning the rollout of Ayushman Bharat, a national healthcare programme to ensure universal health coverage that has two main components. The first is the ambitious National Health Protection Scheme with a coverage of Rs 5 lakh for about 50 crore beneficiaries each for secondary and tertiary care hospitalisations. The second is the establishment of health and wellness centres to bolster grassroots primary healthcare.

Patients in India have the largest out-of-pocket expenditure among the BRICS countries and are the sixth largest spenders in the world. This medical expenditure is a major cause of poverty. The National Health Policy 2017 targets catastrophic health expenditure as one of the four priorities it aims to address. Catastrophic health expenditure is spending that is so high that the family is forced to borrow money or reduce other essential expenditure.

India has tried out many universal health coverage models based on health insurance that mainly cover certain procedures at hospitals in the hope of reducing catastrophic expenditure. The biggest among these schemes is the Rashtriya Swasthya Bima Yojana. This national scheme launched in 2008 has, however, proved to be inefficient in reducing out-of-pocket expenditure in poor households. Surprisingly, it increased the likelihood of such expenditure by 30%. A similar case is the Rajiv Arogyasri Scheme in Andhra Pradesh, which was found to have limited impact on catastrophic outpatient expenditure, and did not benefit the most vulnerable scheduled castes and tribes in the state. The state spent 25% of its health budget on diseases that account for less than 2% of its total disease burden – diseases that require expensive interventions like surgical oncology, cardiothoracic surgery, genitourinary surgeries, neurosurgery and cochlear implants.

Insurance-based health sector reforms have also unwittingly widened the patient consumer pool for the private health providers, as some public health experts had forewarned.

However, Tamil Nadu’s universal healthcare programme that focuses on strengthening public health facilities has shown encouraging results. Health sub-centres are the first point of healthcare for the public and generally considered the weakest link in the health delivery system.

Back to basics

The pilot project tried a three-pronged approach to ensure that all these centres are fully functional and to strengthen them. Under the pilot project, 67 health sub-centres in the three blocks of Shoolagiri in Krishnagiri district, Viralimalai in Pudukottai district and Veppur in Perambalur district were refurbished to ensure that they had adequate infrastructure, water and electricity. They were also provided with adequate stocks of drugs and diagnostic tests for basic ailments. Each of these centres already had one Village Health Nurse or VHN and efforts were made to employ a second such nurse at each centre. This was to ensure the availability of a health worker throughout the day on all working days. The government also set up an IT platform for patient data collection.

Outpatients at the health sub-centre at Viralimalai block in Pudukottai district in Tamil Nadu. (Photo: Adithyan GS)
Outpatients at the health sub-centre at Viralimalai block in Pudukottai district in Tamil Nadu. (Photo: Adithyan GS)

The project was independently evaluated in February by researchers from the Centre for Technology and Policy at the Indian Institute of Technology, Madras, and a report has been submitted to the state’s Department of Health and Family Welfare. The report shows that the interventions led to a dramatic increase in patients accessing the 67 health sub-centres. The percentage of outpatients accessing the health sub-centres before the pilot project was less than 1% but this jumped to between 15% and 23% after the project was implemented. Additionally, the sub-centres functioned better as gatekeepers to the larger health system. With more patients being treated at the health sub-centres for minor ailments, fewer outpatients went to primary health centres and community health centres, thereby decreasing the load on the higher primary care facilities.

Another benefit of strengthening the health sub-centres showed up in the number of patients going to private clinics and hospitals. In less than a year, the share of outpatient visits to private health facilities dropped to 21% from 51% in Shoolagiri, to 24.2% from 47.8% in Viralimalai, and to 23.9% from 40.9% in Veppur.

Patient expenditure also dropped significantly. Patients spend less than Rs 5 out-of-pocket at health sub-centres in the project blocks. Patients spent much less on outpatient visits at the sub-centres than they earlier did at out-patient departments at bigger public hospitals or private clinics. In fact, total out-of-pocket expenditure per outpatient visit across facilities fell from Rs 261 to Rs 59 in Shoolagiri, from Rs 351 to Rs 26 in Viralimalai and from Rs 395 to Rs 67 in Veppur. This was because patients spent less being treated at the health sub-centres than they were earlier spending on travel for treatment of the same ailments at larger public health facilities that are farther away.

The project is now being up-scaled and the Tamil Nadu government plans to transform 985 health sub-centres into Health and Wellness Centres as envisioned under Ayushman Bharat. The promising results indicate that better health outcomes at lower per capita health expenditure are possible through a stronger publicly provided comprehensive primary healthcare model, as opposed to insurance schemes availed at either public or private health facilities.

Insurance schemes generally have no fail-safe mechanisms to control supplier-induced demand. For example, doctors may prescribe unnecessary tests, medicines and procedures to get insurance payouts. Experts have reiterated that the National Health Protection Scheme is also likely to have this gap and that it continues to ignore primary healthcare and outpatient care. The government would do better to focus on its Health and Wellness Centres initiative. However, given the lack of substantial budgetary commitments, this initiative looks more like a game of numbers with the government cosmetically changing 1.5 lakh health facilities into Health and Wellness Centres before the next general elections.

If the government does have the will to implement actual change, it would do well to follow the example set by Tamil Nadu in its pilot universal healthcare project.

Nafis Faizi is an Assistant Professor of Community Medicine, at JN Medical College, AMU, Aligarh and a voluntary trainer for Public Health Research and Assistance Society (PHRASe) on research methods, design, biostatistics, software and research dissemination.

Adithyan GS is a public health professional, currently working in Tamil Nadu. He holds a public health postgraduate degree from the School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.