Redesign our healthcare system

Many health experts and policy commentators have stressed the need for strengthening primary care system in the country. They believe, not without reason, that diagnosing and treating health conditions at early stages will mitigate the flow of patients to hospitals, which is not only better for patients’ well-being but also for the health system as it will reduce avoidable disease burden. Strengthening of primary care system in India calls for its redesign as the current design, which is almost the same in all states, has become archaic in terms of how it is financed, how the care is organised, what healthcare services it provides, what incentives and accountability mechanisms drive the system and so forth.

The primary care system needs to be designed to engage intensively with the population in managing their health conditions. Intensive system engagement implies that the health staff meets more frequently and spend more time with the population in providing healthcare services, in providing health education, and in monitoring population health closely. Except for the maternal and child health services for which there is some active engagement at the community level, the current system passively treats patients as and when they show up at a health facility; it doesn’t actively manage their health conditions. This approach needs to change. Health of every person needs to be accounted and managed.

For this to happen, the primary care system must be designed to meet most healthcare needs of the population by offering a wider package of healthcare services than it currently does, and that such services to be delivered at household, community and at health facility level.

This means the primary care delivery system — which currently consists of a vast network of community as well as primary health centres, sub-centres, and field staff and volunteers — needs to be totally reconfigured in the light of wider service package to be delivered at different levels.

The reconfigured primary care system needs to be incentivised to perform well, which is possible, if the amount paid is linked performance. The current primary care system in India is largely input-financed which provides for certain level of inputs independent of performance. The input-based funding model works well in the presence of a strong internal supervision and top-down accountability with a sharp eye on performance. Unfortunately, this model has not been serving us well as we’ve not been able to provide the conditions necessary to make this model work well.

A capitation based system, in which a health unit is paid on the basis of population enrolled with the health unit and additionally on certain indictors defined at population level, is a performance-based system. Some developing countries such as Thailand and Turkey have successfully adopted a capitation-based system. A capitation-based system has a number of advantages such as driving performance through incentives (and not so much by competition that is almost absent in rural areas), reducing inequalities in spending patterns that can otherwise be huge and so forth. Further, if the population is fully covered by the public system, there is little scope for doctors to have private practice. However, the risk associated with introducing a capitation-based system is that population may take its own time to pro-actively take advantage of it. This risk can be mitigated through intensified IEC.

In a public delivery system, a capitation-based system typically goes well when there is a clear separation between purchaser and providers of care. This separation is necessary for accountability, cost control and service quality. This separation also tends to sharpen the “value for money” dialogue between the financers and providers of care. Currently that happens in a crude fashion between finance and health departments. India being a federal country where health service delivery is state’s responsibility, this separation needs to happen at the state level.

Except in case of emergency, the first point of contact for the population always ought to be the health unit/team where they are enrolled and it is these units who should be referring patients to higher level of care in case of need. Patients can be incentivised to follow the referral mechanism. But for this to happen there ought to be a robust primary care system in which people have confidence.

A redesigned primary care system along the above lines will definitely be more resource intensive in terms of health manpower and public funding, both of which are in short supply at present but are expected to ease considerably overtime.

Phasing in of the new design, after it is pilot tested, can be calibrated to the easing of these constraints. A redesigned primary care model needs to be the model of the future.

The writer is a development economist, formerly with the Bill & Melinda Gates Foundation and the World Bank. He can be reached at ahujaahuja@yahoo.com