BongoVongo1

- Universalizing Access To Primary Healthcare

Healing Touch

ANANNYA ROY, University of Calcutta, Kolkata

ARUNI MITRA, Indian Statistical Institute, Kolkata

MANISIT DAS, Indian Institute of Technology, Kharagpur

RAKTIM KUMAR NAG, Jadavpur University, Kolkata

SOUMIK BANERJEE, University of Calcutta, Kolkata

Reasons for selecting the topic:

• India performs even worse in terms of health indicators than overall human development.

• India ranks 136 in terms of HDI (2012). In terms of just Health Index, India’s performance is even worse – it ranks a dismal 142.

• Even Sri Lanka (rank 62) and Bangladesh (rank 122), with much lower income, performs better than India in terms of health indicators of Human development.

• Agriculture still forms the backbone of our economy. Adding to that, nearly 70% of India’s population lives in rural areas. Hence, health of the rural people is of utmost importance. And better health would diminish India’s spending in the long run and the domino effect started by a ‘healthy rural India’ would certainly lead to higher GDP and HDI rank.

• Huge scope of making India “healthy”.

PRESENT CHALLENGES

Posts Vacancies (in %)

PHC Doctors 10

CHC Specialists 63

PHC+CHC nurses 25

Pharmacist 27

Lab technician 50

Short supply of trained doctors

& health workers.

0.599 physicians

/ 1000 population

Nurse to Physician ratio 2:1

Devoted time per patient is meagre

PostsDensity (per 10000 population)

Rural Urban

Allopathic Physicians 3.3 13.3

Nurses & Mid-wives 4.1 15.9

Average Rural Sub-Centre caters to 4 villages within a service sub-centre of 2.61 km.

Limited reach of Primary Healthcare

Difficulty in recruiting and

retaining high quality doctors

in disadvantaged areas

Source: Strengthening of Primary Healthcare-Key to Deliver Inclusive Healthcare, Indian Journal of Public Health.

People believe

whatever is ‘free’ is

‘worthless’.

Direct cash transfer

better than subsidies,

but the latter may lead

to conspicuous

consumption

Medical “fair-

price shops”,

housing both

generic and

patented drugs

‘Dadan’ system: Govt. enters

into an agreement with the

pharma companies such that it

will buy the drugs at a price

enough to compensate the latter,

but lower than the market price,

in lieu of wider market

Break the nexus

between doctors and

pharma companies

People get access to medicines

and other diagnostic services

according to one’s need and

financial ability

Make it “cheap”, not “free”

POLICY PRESCRIPTION

1. MEDICAL FAIR PRICE SHOPS

Preventive Healthcare:

• Educate people about hygiene.

• Introduction of e-Toilets, Bio-toilets for the same.

• Inculcate family-planning ideas among the rural folk.

• Imparting awareness of preventive measures for common prevalent diseases.

POLICY PRESCRIPTION

2. ALTERNATIVE MEDICINE

AYUSH Practitioners:

• Unconventional therapies like Unani (palliative medicine),Homeopathy, Ayurveda (for non-epidemic cases scenario) -cost effective, less or no side-effects, mostly natural medicines.

• Certified AYUSH practitioners should be allowed to prescribeallopathic drugs during emergencies(after some integratedtraining) – help in curbing quacks and ensure that rural peopleget timely treatment.

• FACT: Several PHCs in remote areas are still run by AYUSHpractitioners, yielding better than anticipated results.

How does the system work?• Instead of an MBBS course, a shortened, subsidized

diploma course on basic medical training.

• A 3-3.5 years course on rural health and healthcare(on the lines of B.Sc. in rural healthcare practised inAssam & Chhattisgarh).

• Basic training involves techniques that can handleemergency situations and, help detect and curecommon prevalent ailments.

• Focus more on Preventive healthcare than curative.

• Preferential selection of rural students for trainingwill help retain the ‘para-doctors’ to rural areas.

• Para-Doctors need to travel and should always beequipped with basic and emergency medicines andequipment.

Auxiliary Force• Increase in the number of nursing graduates

and post-graduates who could be posted inrural areas.

• Mandatory rural posting after MBBSinternship.

POLICY PRESCRIPTION

3. PARA DOCTORS

•Flexible Hobson’s Choice - Make the medical students sign a bond mentioningthat everyone has to serve in the disadvantaged areas for at least 2 years. Theservice can spread over 4 years, serving for at least 4 months in a stretch (suitableoptions).

• In case of violation of the above, medical students would need to pay theenormous subsidies the government spent on them. Else, graduation certificateswon’t be issued.

•The introduction of differential salary system – higher salary and otheremoluments for doctors willing to work in remote areas.

•The provision of decent living quarters and family facilities(specially children’stuition allowance) for the doctors in rural areas.

•Faster rank promotion for rural medical practitioners. The Govt. can create newerposts with little increase in salary but higher ranks – should instill confidenceand encourage the doctors.

•Provision of innovative benefit packages (for example- providing nurses orjunior doctors with car allowance, something that only senior staffs get in thecities).

• Incentives for rural health workers who can promote preventive healthcare.

•Offering specialist training as incentive.

4. Incentive-

Compatible Schemes

(i) Health Subsidies may not move

the poor above a critical level of

steady income. Health Insurance

can deliver exactly that by

absorbing the contingency risks.

(ii) Facilities can be availed even in

private hospitals

People believe

whatever is ‘free’ is

‘worthless’.

Basic medical costs

seem very high to

the rural poor

A co-operative scheme of Health Insurance

• People form a group and each person saves a small amount of money.

• A co-operative insurance account is created.

• If anyone of the group falls ill, he/she is insured through money from that account.

Why is Health Insurance better

than subsidies for a poor person?

5. REFORMED

HEALTH

INSURANCE

Monitoring Mechanism : Each and every expense should be accounted for. Apart from separate CAG boards to oversee the movements, a detailed account of expenses

should be uploaded on a government website(maintained by private company, so better security) for the public to view and question any irregularity or suspicious expense(to be compared against the official govt. sanctions/records). This step can help check the any

large or small scale embezzlements (like the UP NRHM scam).

Stakeholder’s Involved:

• The Government

• The Medical Practitioners and AuxiliaryForce (nurses, mid-wives and others).

• The Pharmaceutical Companies.

• Community.

Proposed Sources of Funding(apart from Government sanctions):

• The education subsidies that will be cut off from those students unwilling to be posted in ruralareas can be used to finance the diploma course and the necessary infrastructure.

• The Health Insurance Scheme is almost self-financed.

• Mandatory CSR initiatives on part of the MNCs.

• 2 way benefit project by implementing innovative marketing strategies. Example –a companyX takes the responsibility of building and operating health centres in a village and in returnask them to rename the roads or the village to X or things related to X(something in the linesof Snapdealnagar).

A GIANT LEAP FORWARD… Replacement of top-down approach by a holistic development model:

Our model of healthcare service calls for a change in workplace culture from hierarchical to relational management, through better language-compatibility and stronger mesh of human bonds.

From “Financing Subsidies” to “Subsidizing Finance”:

Instead of financing a huge subsidy-bill for healthcare facilities, we call for subsidizing the health insurance premium rates so that the poor folk can afford such financial instruments.

Abhijit Vinayak Banerjee and Esther Duflo. Poor Economics (2012).

Bulletin on Rural Health Statistics in India, 2009: http://www.mohfw.nic.in/NRHM/BULLETIN%20ON.htm.

Government of India. Faster, sustainable and more inclusive growth: An approach to the 12th five year plan. New Delhi, 2011: http://planningcommission.nic.in/plans/planrel/12appdrft/appraoch_12plan.pdf

International Institute for Population Sciences and Macro International (September 2007). "National Family Health Survey (NFHS-3), 2005-06". Ministry of Health and Family Welfare, Government of India. p. 436-40.: http://www.measuredhs.com/pubs/pdf/FRIND3/FRIND3Vol1AndVol2.pdf

Yeravdekar R, Yeravdekar VR, Tutakne M A, Bhatia NP, Tambe M. “Strengthening of Primary Healthcare-Key to Deliver Inclusive Healthcare”. Indian Journal of Public Health.

References