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  1. 1. Universalizing Access To Primary Healthcare • Dr. Yogesh Dukare • Shweta Bharti • Shilpa Gaur • Himani Jain • Chinar Sharma Team members
  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 Indian Health Care Delivery Structure 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 : 2
  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 3
  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. 25% 6% 6% 27% 23% 13% Qucik attention Lack of specialists Can afford Less waiting time Doctor availability No free medicies in govt. 4 Why Indian people prefer Pvt. healthcare services
  5. 5. Infrastructure: Current status and road ahead • Currently overall bed availability – 9/10,000 people • Skewed proportion within rural & urban area as well as from North India to South India Availability of beds 5 Rural Urban Population of India 893874211 347617749 Number of Beds 454580 882420 Hospital Beds/10000 5 25 Supply Gap w.r.t Global average 2227043 160433 Total Gap 2387476 SHC PHC CHC SDH & DH Current availibility 147069 23673 4535 1579 Expected by 2020 314547 50591 12648 5203 0 50000 100000 150000 200000 250000 300000 350000 Current availibility Expected by 2020 SHC: Sub-Health Center PHC: Primary Health Center CHC: Community Health Center DH: District Hospitals Number of Primary Healthcare facility: Current & proposed
  6. 6. Proposal for Infrastructure improvement 6 • 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 services • Implementation of a robust Hospital Management Information System across all centers to share real time information about patients & treatment modalities Infrastructure Planning Some successful Public –private partnerships in Government healthcare infrastructure
  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 7
  8. 8. 8 Human Resource Management- Scope for improvement 8 Incentivisation Substantial monetary incentives which is performance based and varies according to the difficulty of the area 11 Compulsory Rural Service Making two years of rural service compulsory in public hospitals to a post graduate medical student 22 Decentralization Related Options Decentralization of decision-making on recruitment and financing to district or block Panchayat or hospital development committees for medically underserved remote areas Doctor alternatives & Training of paramedical All PHCs support staff should have an induction training of 1 month imparting basic clinical multi-skills them and then a refresher of 15 days once in 2 or 3 years. 33 Professional Motivation for doctors in PHC CME scheme for Skill upgradation programmes, ensuring access to drugs & equipments related to their field of specialization, 44 Training AYUSH practitioners If AYUSH doctors are playing medical officer roles then they should be provided intensive skill upgradation programmes 55 77 88 66 Active Referral Systems Active referral system with feedback from referral institution to the doctor referring enabling the patient to be primarily managed at the lower center clear understanding of who should be referred avoiding high degree of unnecessary referrals Regular Monitor, Progress Against Standards Setting IPHS Standards ,Facility Surveys to gain performance data of PHCs, Independent Monitoring Committees at block, district and state levels
  9. 9. ANM • Increase of ANM/ sub center 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 Human Resource Management- Scope for improvement
  10. 10. Planning & Integration Medicines Referral System Diagnostic Services 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 • Mandatory 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 specialty • Expert consultation & advice through Telemedicine Monitoring of referred Patient and feedback along with integration • Govt Subsidy on essential Diagnostic tests • Performance based incentives to doctors • Standardization of laboratory equipments on regular basis by regulatory body • Formulation of Village Community Insurance Scheme • Banking Contribution From Priority Sector Lending 10
  11. 11. 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 minimum essential ddiagnostic 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 CSR Policy Change Increased Insurance penetration by special incentives, subsidies to private players Affordability 11
  12. 12. 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 12
  13. 13. 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 13