66 I April 2013

Policies & Regulations: Transforming healthcare delivery

How strengthening the primary care system would help…

If we address the primary care and reform it, the bene!ts are multi fold. First, the healthcare problems of the population can be addressed at

an early stage, so the population becomes healthier and more productive. Second, the overall expenses on healthcare can be reduced by preventing the aggravation of the disease, and so, as people would get primary care at the point of illness (village), patient load on district and tertiary care hospitals would go down drastically.

Let us take an example; in a village which is about 60 kilometers from a district hospital (this is the average distance in

India between a sub centre at the village and the district hospital, though some district hospitals are about 100 kms from the village), if a person falls sick , what are the various stages of treatment?Stage 1: Do nothing for few hours hoping that the problem will subside or cure on its own. O"er prayers…ironically, prayer is the !rst line of treatment in India.Stage 2: Seek the guidance of elderly in the family and take to home remedies. Traditional system of medicine is the second line of treatment. Stage 3: Reach out to the village doctor or the nearest chemist and seek treatment.

Stage 4: Go to a private village/nearby clinic or government run healthcare facility.Stage 5: ‘Rush’ the patient to the district hospital.

Most of the time when the patients reach the district hospital, they go with their families and so, the source of ‘earning stops’ and the ‘spending starts’ the moment a relative lands in the hospital. Also, most of the time the disease has become irreversible and both the money and the lives are lost, leading to a distrust in the healthcare facilities in the system.

How to build trust in primary care?In 2010-11, I was co-architecting a Bottom Of #e Pyramid (BOP) healthcare model for a FMCG global giant. During this time, I was travelling to rural villages in Karnataka (Hunsikatti in Belgaum and Holalu village in Mandya district). I went to the government run village healthcare centre and was shocked to see that there were no patients at all. #e doctor-in-charge informed that since it was ‘festive season’ (Ganesh Chaturdashi) there were no patients and the doctor and the nurse were sitting idle. As we walked out of the government run facility, just a few meters away, we walked past a clinic of one Dr Sudheendra K Shetty, B.M.A.S (I guess there is no such degree like B.M.A.S; but if there is one, please pardon me for my ignorance!). I was surprised to see that outside this clinic there were at least 60 pairs of slippers, indicating that at least 60 patients or relatives were waiting to be examined or being treated inside the clinic. I could not hold myself from entering this clinic and introducing myself to Dr Shetty. I apologised for coming directly to him without an appointment or following the queue, but I praised his work and practice. I told him that never in my working in rural India, I had come across such a successful rural practitioner. I asked him a few questions about his practice, fees etc. Dr Shetty informed me that he had been working for the past twenty years and came daily from 60 kilometers to this village to ‘practice’ here from 8 AM to 8 PM and some times, even stayed late in the night. On being asked about his fees, he informed that he charged ` 20, but if

The Indian healthcare system is undergoing a paradigm shift with many reforms taking place simultaneously; be it universal coverage, rural health, expanding Rashtriya Swasthya Bima Yojna (RSBY), mother and child health, chronic diseases or telemedicine. Under such a scenario, ideally there should be ‘rolling priorities’. That means that set up one priority, address it and then move on to the next one…and the first priority should be transforming the primary care system.

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Transforming healthcare delivery

67April 2013 I

the patient is poor he accepts even ` 10 and sometimes even treats for free. I saw that some patients were lying on wooden benches with a drip (IV) outside his clinic (in the waiting area). Clearly, what the doctor at the government run Primary Healthcare Centre (PHC) told me was not true. Seeing the number of patients at this clinic, it was evident that despite the ‘festive season’, this ‘rural doctor’ saw 120 patients a day and had built the ‘trust’ among the people . I had asked Dr Shetty at the time that why do people come to him and not go to the PHC? And he told me that, ‘he had been serving these people for over 20 years and was available when they needed him!’ !is is one major reform is missing in the primary care in rural India and also among the urban poor – ‘Availability’.

!e healthcare systems are not geared towards ‘serving’, ‘communicating’ and building trust with the care seekers. So, what can we do to reform primary care in India and build trust. Build a primary care delivery model

where people do not have to come to the doctor when ill, but a system which proactively reaches out to people and focusses on communication, communication and just communication! Because knowledge transfer plays a key role in an outcome-driven healthcare system. Communication can be a 360° communication, which means it can be powered by ICT, Flip charts, call centres and one-to-one communication about issues related to health. !e person who does one-to-one communication should be available when needed. We should think about converting village health centres into a 24 X 7 service, backed by essential medicine and equipment to treat emergencies. It can be onsite or a ‘clinic on ambulance’ model.

We have over 800,000 ASHAs. ASHAs are class 8th pass married females from the village who provide advice and treatment with OTC medications (non-prescription products). Why can we not have applications loaded in cell phones that have the information about common ailments with advice and treatment guidelines with respect to OTC medications? !is way, we

can have every rural Indian taking to ‘self care’ for a common ailments, and not get panicked or not take any medication, if unwell. If this system (Apps on the mobile) is linked to the nearest cell network (cell phone tower can direct it to the nearest sub-centre/health volunteer), and the medication supplied at his home through the ASHA or health volunteer in the village, it would be a good start to clinical primary care. !is way, we will build the trust with the village residents and also save them from aggravating their problem by not doing anything and waiting for the worse to happen and rushing in the last moment to the district hospital! Moreover, the cost

of this technology intervention would be very low. If just by taking the OTC medication they get well, "ne. Else, they can SMS to a toll free number and they will get a call from the nearest health centre to guide them on the next steps. If the problem is serious, the call centre can book their appointment at the nearest PHC or empanelled hospital for treatment and the ‘clinic on ambulance’, can ferry them. Following this system, we can at least reduce 40 per cent of the OPD load from district hospitals and be more e#ective in delivering primary care.

Strengthening the prime factorPrimary care should be the primary concern, as spending more on primary care will lead to spending less on tertiary care. We know pretty well that a major heart intervention would cost an average of ` 1.5 lac or a renal failure can lead to recurring unbearable expenses for a common man, but if primary and preventive care is available at the right time, the need for these expensive chronic interventions can be avoided or drastically

reduced, as an OPD consultation would cost even less than ` 100. So, the right inputs at the correct time can prevent a chronic disease-related emergency condition, which today sends 40 million people below the poverty line every year in India.

It is a known fact that 80 per cent of the funding of National Health Service (NHS) UK under the NHS reforms, was meant for the Primary Care Trusts (PCTs) and GP consortia. A healthcare system with weak primary care can never be strong and will always fail to deliver, no matter how much percentage of GDP is allocated for healthcare

Also, primary care must focus on prevention and wellness and not on treatment. Today’s primary care is more of a "rst line of treatment for an illness. May be, it would be a good idea to consider to pay Family Physicians and General Practitioners (GPs) more salaries than specialists, and this way, we can encourage more medical graduates taking to these ‘specialties’ . It is time to think radically di#erent to revive primary care.

Also, technology can come as a saviour for reviving primary care and this must be leveraged

India must seriously consider elevating the role of nurses and pharmacists in primary care. !is one step of deploying nurses and pharmacists for primary care as Physicians Assistant (in addition to doctors) will deliver tremendous results.

Private sector must show its commitment to Public Private Partnerships (PPPs) by taking primary care as its challenge. !ere should not be a PPP in tertiary care without a PPP in rural sub-centre. We certainly need a nationwide primary care clinic network on a PPP model. Primary care remains the primary challenge, and it is time to ensure that primary care is focused on prevention and wellness. !is will be the best gate keeper of the healthcare system for ensuring lower cost and better clinical outcomes

(o!ce@rajendragupta.in)

Rajendra Pratap Gupta International Healthcare Expert, President, DMAI

India must seriously consider elevating the role of nurses and pharmacists in primary care. This one step of deploying nurses and pharmacists for primary care as Physicians Assistant will deliver tremendous results.