When the primary healthcare system is not functioning optimally, it increases the pressure on the tertiary health facilities. Overloading the country’s tertiary medical institutions, the second wave saw 50% of its caseload coming from rural India.
Health is not everything, but without health, everything is nothing.
Arthur Schopenhauer
FORT LAUDERDALE, FLORIDA, US: As SARS-CoV-2 continues to plague even our largest economies, India is no exception. After making groundbreaking progress in global vaccine contribution through Covishield and Covaxin, the country had the highest per-day positive cases in the second wave. It is not likely that over a billion Indians will be vaccinated sufficiently to stop the spread properly or in time for the next wave. What can India do to combat this? The answer lies in how healthcare is currently provided and how it can be reshaped to address fundamental issues at the heart of providing quality care.
Each state must provide universal access to healthcare services, but many states find themselves lacking the resources to make this possible. Out of the total medical visits in India, nearly 86% of them are being made by individuals from rural communities who travel more than 62 miles. Expenses are paid out of pocket, leaving these individuals in poverty. A report based on a study of 143 public facilities in India found a lack of doctors, unpredictable hours, and essential equipment and medicines. Therefore, addressing resources and infrastructure issues is necessary at the national level.
One of the biggest challenges is the lack of functioning primary health facilities. Although the numbers of these facilities continue to increase, there is not enough staff for these facilities to function. If more facilities were opened, they would also suffer from the same staffing shortages and essentially be inoperable.
When the primary healthcare system is not functioning optimally, it increases the pressure on the tertiary health facilities. Overloading the country’s tertiary medical institutions, the second wave saw 50% of its caseload coming from rural India.
Ineffectiveness throughout primary healthcare has left a breach in the referral system, which should be serving as an entry point and then providing continuous comprehensive coordination at all healthcare levels. A sub-health centre is where vaccinations and testing for Covid-19 should be occurring, but many of these sub-health centres are neglected and lacked even essential personnel to run them.
The truth is that while the healthcare system deals with Covid-19, other aspects of healthcare are being ignored or neglected. Parents are not bringing their children in for routine vaccinations. Prenatal checkups are being missed. Patients are not picking up medicines for chronic illnesses. The fact that India’s healthcare system is failing to run routine functions during the pandemic indicates a change is vital to protecting the future health of our people and nation. Structural and functional reforms throughout the healthcare system can be critical to managing the next wave while improving the healthcare system for decades to come.
India cannot continue to respond to emergencies with this Band-Aid approach. There must be investments of time and funding to stabilize the foundation of healthcare throughout this country. States managing their healthcare has led to a piecemeal approach, and a federally guided system is key to providing equitable healthcare to all and addressing infrastructural issues.
URGENT NEED FOR INVESTMENT
The public healthcare system in India is chronically unfunded. The latest available data before the pandemic showed India was spending about $73 per person annually on healthcare, while the United States was spending $11,582 per person. US healthcare spending alone is $4.1 trillion per year, which is higher than the entire Indian GDP of $2.9 trillion. India currently spends about 1% of GDP on health, among the lowest for any major economy.
Finance Minister Nirmala Sitharaman’s proposal to increase healthcare spending to 2.2 trillion Indian rupees ($30.2 billion) to help improve public health systems and fund a colossal vaccination drive to immunize 1.3 billion people is a good start but merely a drop in the bucket for what is needed for structural reform.
STATUS OF RURAL PUBLIC HEALTHCARE
To understand how Indian healthcare can be better prepared to manage the third wave of Covid-19, one must understand the historical problems faced by the Indian healthcare system, especially in rural India. Under India’s decentralized healthcare delivery approach, the states are primarily responsible for organizing health services. Because of severe shortages of staff and supplies at government facilities, many households seek care from private providers and pay out-of-pocket.
The Constitution of India obliges the government to ensure the “right to health” for all. Each state is required to provide free universal access to healthcare services. However, healthcare in India has been chronically underfunded. Systemic barriers to access include long wait times in hospitals, the perceived low quality of public health services, and substantial workforce and infrastructure shortfalls.
Reports continue to emerge of sub-optimal functionality of several PHCs in villages. Most of these reports reflect more significant issues, including workforce shortages, absenteeism, and poor infrastructure, leading to a more inferior quality of care.
Controlling Covid-19 often starts with early detection and management. Community-based management of this pandemic is necessary to reduce the burden on the tertiary health facilities. Yet, the ability of the primary healthcare system to do this is limited at best and non-existent at worst. The result is individuals flooding cities and overwhelming a fragile system with limited resources available, including oxygen.
Systemic barriers to access include long wait times, a perception of low quality of public health services, and the shortfalls of both workforce and infrastructure. Changing this will require the political will to invest in the Indian people through technology, building relationships, and increasing the number of doctors, nurses, and staff at all levels of the system. The question is how to build a workforce to meet the needs of the Indian people, both in the rural and urban areas of the country, mainly when there are shortages of people, facilities, equipment, and more.
NEED FOR PUBLIC HEALTHCARE CIVIL SERVANTS
Government hospitals are currently managed by doctors promoted based on their seniority and not based on their training in hospital management, while professional hospital managers manage the private hospitals. Managing a public health system for the largest population in the world is not an easy task, even for the best doctor with decades of experience in patient care.
Indian civil services select and train senior bureaucrats who lead the Indian government. India currently has several IAS and IFS officers with MBBS training. I propose the Government of India create an Indian Health Service (IHS) Branch. India will need 742 “IHS” officers, one per district, who are ranked equal to the IAS officers to coordinate the public health system of the district. By creating a civil service branch to manage healthcare centres and increasing medical and nursing colleges to one per district, a large workforce could be made available to staff these facilities adequately.
Work in rural areas could also be mandated, allowing for communities and villages to receive quality care. For instance, part of a doctor’s training could include a year or more service in a rural village working in a primary care centre. Other options include incentives to reduce educational costs in exchange for time served in a primary healthcare centre.
TELEMEDICINE AND SMART PHCS
With the crisis pushing us to innovate, investing up to 5% of India’s total gross domestic product could be vital in building a telemedicine-capable primary health centre or sub-centre in every Indian village. Smart PHCs could be managed by collaboration with charitable institutions or NGOs. India will also need to increase technology and healthcare educational opportunities for individuals looking for a healthcare career. Creating a medical college/district hospital in every district linked by a telemedicine network for referrals and specialty consults to the smart PHC or a sub-centre in every village will be vital to providing state-of-the-art healthcare access to rural India.
THE WAY FORWARD
With one of the largest populations in the world, India could lead the world in providing quality healthcare to all its citizens. All the pieces are there, from technology to manufacturing. Implementing these changes will take Investment and planning, but it is not out of reach. Multiple scientific advances in the 21st century have given us a lifeline in nature’s arms race. The world, however, remains in turmoil over SARS-CoV-2, which is continuing to plague even our largest economies, with India being no exception.
The biggest democracy in the world needs urgent investment in the health of all its citizens and reform the public healthcare system.
Prof (Dr) Joseph M. Chalil is an Adjunct Professor & Chair of the Complex Health Systems advisory board at Nova Southeastern University’s School of Business; Chairman of the Indo-American Press Club and The Universal News Network publisher. He recently published a best seller book, “Beyond the Covid-19 pandemic: Envisioning a Better World by Transforming the Future of Healthcare.”