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  1. 1. Universalizing Access To Primary Healthcare Team Details • Yogesh Dukare • Shweta Bharti • Shilpa Gaur • Himani Jain • Chinar Sharma
  2. 2. Medical college SDH/District hospital 1/100000 population Community health center 80,000-12,000 population Primary Health Care Center 20000-30000 population Sub-health center 3000-5000 population Sub centre covers a population of 5000 in plain areas and 3000 in Hilly and difficult terrains Health Care delivery Architecture Tertiary level Primarylevel Secondary level Ensuring equitable access for all Indian citizens residents, any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessary the only provider of health & related services. - HLEG , Planning Commision of India What is Universal Health Coverage The “first” level of contact between the individual and the health system. It is provided by Subcenters , Primary healthcare centers & Community Health care Centers . Primary Health Care :
  3. 3. Reasons for poor healthcare structure in India Insufficient funding of public facilities Physical reach of any healthcare facility is a challenge in rural areas, particularly for patients with chronic ailments Lack of availability of medical services Inefficient management of available financial & human resources The provision of healthcare services in India is skewed toward urban centers and the private sector Improper planning & allocation of resources Financial inability to pay (Around 70% of total health spending is out of pocket, and around 70% of that is on drugs. Non availability of doctors in public health facilities is a key reason for selecting private facility outpatient treatments Even if only one of these components is missing, a patient is unlikely to receive appropriate healthcare service. Physical accessibility of required healthcare facilities for a patient Availability of the resources required for patient treatment Quality/ functionality of the resources providing care Affordability of the complete treatment to the patient. Complete primary healthcare
  4. 4. Roadmap to improvement in health care delivery status Roadmap to improve primary healthcare system “The healthcare system in India is not delivering affordable, acceptable and accessible healthcare to all Indians – which must be the test of its quality. Fixes to only parts of the system cannot produce the systemic changes required. - Arun Maira, member, Planning Commission of India. Qucik attention 25% Lack of specialists 6% Can afford 6% Less waiting time 27% Doctor availability 23% No free medicies in govt. 13% Why people prefer private hospitals
  5. 5. Infrastructure: Current status and road ahead 0 100000 200000 300000 400000 SHC PHC CHC SDH & DH Current availibility Expected by 2020 • Currently around 0.9/1000 people, excluding PHC • Faulty planning led to under/over utilized hospitals from rural to urban as well as North India to South India • Need-based allocation of beds, medical equipment • Increasing tax to GDP ratio over 15% through non-linear taxation to generate more funds • Focusing on ease of access, within a 5km distance • Strategic partnership/ outsourcing with key private players • Standards for man-hours and skill set required at each center, other infrastructure like ambulance • Implementation of a robust HMIS system across all centers to share real time information and analyze and track growth Availability of beds Infrastructure Planning
  6. 6. Infrastructure Current status & roadahead Health Care Delivery Medical Colleges Nursing Colleges Dearth of Quality & Trained HC Professionals. Faculty recruitment Retention Attracting quality students Poor Infrastructure & reach to Tier 2/3 cities. Maintaining bed occupancy rates in Teaching hospitals Limited ability to provide clinical training Insufficient Clinical Exposure for Professionals Strict regulatory norms Limited financial assistance for students Limited Opportunity for continuous learning Non Standard content Low quality curriculum Brain Drain Limited research funding/High equipment cost Limited experienced Faculty & absenteeism
  7. 7. Human resource management 0 8 16 24 WHO India 23 19 Heath HRM/10000 Population India ranked 52 of the 57 countries facing an HRH crisis. •34% for MHW are not in position, while 38% of radiographer posts, 16% of lab Tech posts, 31% of specialist posts, 20% of pharmacist posts, 17% of ANM posts, and 10% of doctor posts are vacant.. Shortage •A.P, Karnataka, Kerala, Maharashtra, Pondicherry and TN represent 31% of the population, but have a high share of MBBS seats (58%) and nursing colleges (63%) •Bihar, Chhattisgarh, Jharkhand, M.P, Orissa, Rajasthan, Uttaranchal and U.P which comprise 46% of population, have 21% MBBS seats and 20% Nursing colleges . Skewed Distribution HRH shortfalls range from 63% for specialists to 10% for doctors, and 9% for ANMs, respectively
  8. 8. Measures to Overcome the HRH Shortage in Rural Areas ANM •Increase of ANM/ sub centre from 1 to 2- can go to field on alternate days and can ensure 6 days/week working •Get ANM and MPW pre service training centre functional. •In areas where it is difficult to find workers, especially in tribal areas, introduce vocational training for students in class 12th that leads to ANM’s and MPW’s. •Ensure regular annual refresher training for ANM’s and MPW’s •Provision of short term courses on multi skilling. Doctor •Improve the facilities and annual intake. Annual output/ medical college in China 900+ and in India 100+. •Incentivisation of doctors by paying higher salaries for doctors working in rural and tribal areas. Also include performance based incentives as a component of salary. •Compulsory rural postings for MBBS Students and a requirement to apply for Post Graduate programs. •Regular upgradation through CME’s and short term courses on emergency and life saving skills. •Policies to avoid brain drain
  9. 9. Measures to Overcome the HRH Shortage in Rural Areas Allied Practitioners •Nurse Practitioners: Pick ANM or pharmacist and provide curative training but short term. Attend MBBS course but allowed to skip firs one and a half year of course. •Provision of video conferencing to deal with absence of qualified doctors. •Internet facility availability in rural area and training of the staff. •AYUSH Practitioners: Recognition of the Intensive skill up gradation programmes, •Paramedical staff training to perform primary wound care, labs services and community rehabilitation. PPP •NGO’s should be aligned with the program to seek help from corporate houses to initiate health related programs as CSR initiatives. Corporate houses can adopt village and provide basic health and sanitation facilities. Set up health camps to aid in detection, treatment and prevention. •Setting up of hospitals and colleges by charitable organizations on St. Johns medical college, Bangalore pattern where students are charged less fees but they have to serve in rural areas on completion. •Involvement of Panchayat’s to provide assistance workforce and services.
  10. 10. Planning & Integration Insurance Referral Diagnostic Medicines Medicine Referal System Community participation • Stock of 30-50 essential medicines at all time based on the frequency of requirement • Stock filling every week from District Hospitals with all essential medicines • Prescription of generic drugs for cost effectiveness • Strict control of FDA on quality & manufacturing of drugs • Use of IT system to maintain database of referral centers/doctors for each disease category & clinical speciality - Telemedicine •Expert consultation & advice through Telemedicine Monitoring of referred Patient and feedback along with integration Diagnostic Govt Subsidy on Diagnostic tests Performance based incentives to doctors Formulation of Village Community Insurance Scheme Banking Contribution From Priority Sector Lending
  11. 11. Public –Private Partnership Public- Private Partnership Internet & Database Internet & Database DoctorDoctorPHC ParamedicParamedic PatientPatient Mobile cab- 1 cab per 2500 sq KM area Infrastructure( land, concessional equipment, laboratory, drugs, staff, IT , Tax Break) Access to credit(interest rates) Monitoring – Daily reporting and testing samples Incentive System to ensure accountability- Indirect performance based ( Funding of incentives in later stage after seeing the performance in quantitative and qualitative terms) Public- Private Partnership
  12. 12. Regulations & strict implementation Current Scenario •Unmanned PHC’s existing in rural areas depriving patients of immediate attention in case of medical emergencies Gap to be plugged •Dearth of trained medicare personnel •High absenteeism rates of the practitioners Roadmap •Compulsory posting of medical practitioners & interns as per the specifications defined by the GOI •Availability of diagnostic facilities at PHC’s Availability Out of he 2% CSR obligation for private players, 25- 30% to be invested in raising more PHC’ s and CHC’s Physical Accessibility/ Reach Increased Insurance penetration by special incentives, subsidies to private players Affordability
  13. 13. Healthcare Access Affordabili ty Availability Physical accessibility Qu alit y Innovative ideas relying less on capital expenditure and more on human capital 1. ASHA worker feedback mechanism routed through Panchayats and on the job training programmes by ASHA workers recognized through village Panchayat feedbacks 2. Identification of people with entrepreneurial instinct, the right amount of knowledge and commitment towards social work to educate and train people in rural areas on how to handle emergencies and first aid treatment Regulations & strict implementation Current Scenario • Most cases of notifiable diseases go unreported as only a few are taken up and followed up by the concerned authorities Gap to be plugged • Lack of stringent implementation and action against the perpetrators Roadmap • Every single case of any of the notifiable diseases to be closely monitored to avoid absenteeism and availability of doses Quality
  14. 14. References (McKinsey, 2012)Engaging consumers to manage Health care demands medical_soultions_september2009_essay_series_india- 00068239 (IMS Health) http://southasia.oneworld.net/peoplespeak/2018india-is-moving- towards-a-system-of-universal-healthcare2019#.UijDiDbnflV http://forbesindia.com/article/universal-health-care/indias- primary-health-care-needs-quick-reform/34899/1 http://social.yourstory.in/2013/03/a-cure-to-indias-ailing-primary- healthcare/ http://rmsc.nic.in/Drug_Procurement.html http://modernmedicare.co.in/articles/diagnostics-in-india-the- beginning-of-a-new-im-%E2%80%9Cage%E2%80%9D/ http://uhc-india.org/reports/hleg_report.pdf