December 4, 2010 Organizing the Provisioning for a Universal Healthcare System1 -Ravi Duggal2The conversion of the existing system into an organized system to meet the requirements ofuniversality and equity and the rights based approach will require certain hard decisions bypolicy-makers and planners. We first need to spell out the structural requirements or theoutline of the model, which will need the support of legislation. More than the modelsuggested hereunder it is the expose of the idea that is important and needs to be debated forevolving a definitive model.The most important lesson to learn from the existing model is how not to provide curativeservices. Across the country curative care is provided mostly by the private sector,uncontrolled and unregulated. The system operates more on the principles of irrationality thanmedical science. The pharmaceutical industry is in a large measure responsible for thisirrationality in medical care. Twenty thousand drug companies and over 60,000 formulationscharacterize the over Rs. 800 billion drug industry in India.3 The WHO recommends about300 drugs as essential for provision of any decent level of health care. If good health care at areasonable cost has to be provided then a mechanism of assuring rationality must be built intothe system. Family medical practice, adequately regulated, along with referral support, andimplemented by a local health authority, is the best and the most economic means forproviding good health care. What follows is an illustration of a mechanism to operationaliseuniversal access to healthcare, it should not be seen as a well defined model but only as anexample to facilitate a debate on creating a healthcare system based on a right to healthcareapproach. This is based on learnings from experiences in other countries which haveorganized healthcare systems which provide near universal health care coverage to itscitizens.Family PracticeEach family medical practitioner (FMP) should on an average have 400 to 500 familiesassigned to him/her by the local health authority; in highly dense areas this number may go upto 800 to 1000 families and in very sparse areas it may be as less as 100 to 200 families. Foreach family/person enrolled the FMP will get a fixed amount from the local health authority,irrespective of whether care was sought or no. He/she will examine patients, make diagnosis,give advice, prescribe drugs, provide contraceptive services, make referrals, make home-visitswhen necessary and give specific services within his/her framework of skills. Apart from thecapitation amount, he/she will be paid separately for specific services (like minor surgeries,deliveries, home-visits, pathology tests, etc.) he /she renders, and also for administrative costsand overheads. The FMP can have the choice of either being a salaried employee of the healthservices (in which case he/she gets a salary and other benefits) or an independent practitioner1 The following discussion is an updated version based on work done by the author earlier at the Ministry ofHealth New Delhi as a fulltime WHO National Consultant in the Planning Division of the Ministry. An earlierversion was published as “The Private Health Sector in India – Nature, Trends and a Critique” by VHAI, NewDelhi, 20002 Email: <email@example.com>3 In addition to this there is a fairly large and expanding ayurvedic and homoeopathy drug industry estimated to beover one-third of mainstream pharmaceuticals
receiving a capitation fee and other service charges. The payments will keep in mind theequity principle, that is where density is high and a larger number of families are enrolledwith the FMP then the per family capitation payment will be lower than in a area of sparsepopulation where per FMP enrollment is lower, etc. The FMP will also maintain family andpatient records which will facilitate both epidemiological assessments as well as evidencebased planning and allocation of resources.Epidemiological ServicesThe FMP will receive support and work in close collaboration with the epidemiologicalstation (ES) of his/her area. The present PHC setup should be converted into anepidemiological station. This ES should have one doctor who has some training in publichealth (one FMP, preferably salaried, of the ES area can occupy this post) and a health teamcomprising of a public health nurse and health workers and supervisors to assist him/her. TheES should also function as a centre for normal deliveries and basic day care services andshould have 5 to 20 beds depending on its population coverage. Each ES should cover apopulation between 8,000 to 20,000 in rural areas depending on density and distance factorsand even up to 50,000 population in urban areas. On an average for every 2000 populationthere should be a health worker (subcentre of one male and one female health worker at 4000population level) and for every six to eight health workers a supervisor. Epidemiologicalsurveillance, monitoring, taking public health measures, laboratory services, and informationmanagement will be the main tasks of the ES. The health workers will form the survey teamand also carry out tasks related to all the preventive and promotive programs (diseaseprograms, MCH, immunization, etc.) They will work in close collaboration with the FMPand each health workers family list will coincide with the concerned FMPs list. At the villagelevel for every 500 population and in urban wards for every 1500-2000 population there willbe a community health worker who will be a link person for the community with thehealthcare system. The health team, including FMPs, will also be responsible for maintaininga minimum information system (individual/patient profile), which will be necessary forplanning, research, monitoring, and auditing. They will also facilitate health education. Ofcourse, there should be other appropriate supportive staff to facilitate the work of the healthteam.First Level ReferralThe FMP and ES will be backed by referral support from a basic hospital at the 50,000population level. This hospital will provide basic specialist consultation and inpatient carepurely on referral from the FMP or ES, except of course in case of emergencies. Generalmedicine, general surgery, paediatrics, obstetrics and gynaecology, orthopaedics,ophthalmology, dental services, radiological and other basic diagnostic services andambulance services should be available at this basic hospital. This hospital will have 50 beds,the above mentioned specialists, 6 general duty doctors and 18 nurses (for 3 shifts) and otherrequisite technical (pharmacists, radiographers, laboratory technicians, etc.) and support(administrative, statistical, etc.) staff, equipment, supplies, etc., as per recommendedstandards. There should be two ambulances available at each such hospital. The hospital toowill maintain a minimum information system and a standard set of records.
Pharmaceutical ServicesUnder the recommended health care system only the essential drugs required for basic care asmentioned in standard textbooks and/or the WHO essential drug list or a similar statepharmacopeia should be made available through pharmacies contracted by the local healthauthority. Where pharmacy stores are not available within a 1 to 2 km radial distance from thehealth facility the FMP should have the assistance of a pharmacist with stocks of all requiredmedicines. Drugs should be dispensed strictly against prescriptions only. The hospitals shouldhave their own pharmacy store. Payments for the drugs will be made directly by the localhealth authority from its budget. Patients should not make any direct payments for procuringdrugs. On a random basis the health authority should carry out prescription audits to preventunnecessary and irrational drug use.Rehabilitation and Occupational Health ServicesEvery health district must have a centre for rehabilitation services for the physically andmentally challenged and also services for treating occupational diseases, includingoccupational and physical therapy. This will be attached to the Referral Hospital.Referral Hospital and Tertiary HospitalFor each 3 to 5 basic hospitals there should be a 150-250 bed hospital at the 150000-250000population level or the Block/Taluka level which would constitute the health district. Thiswould function as a multi-specialty referral hospital for most higher level care, having all thebasic specialties, somewhat akin to the smaller district hospitals that exist today with the samerange of medical, nursing and support staff.As a further referral support each district would have a tertiary or teaching hospital whichwould be the apex hospital for the district. This hospital should be a 500-1000 bed hospitaldepending on the density of the population and would be a multi-specialty hospital with allsuper specialties, like any existing average medical college and hospital.These hospitals from first referral units to tertiary hospitals should preferably be publichospitals but could also be contracted in private hospitals which provide services within anegotiated agreement which is regulated and monitored through a purchase agreement andaudit provisions with the concerned health authority.Licensing, Registration and CMEThe local health authority should have the power to issue licenses to open a medical practiceor a hospital. Any doctor wanting to set up a medical practice or anybody wishing to set up ahospital, whether within the universal health care system or outside it will have to seek thepermission of the health authority. The licenses will be issued as per norms that will be laiddown for geographical distribution of doctors. The local health authority will also register thedoctors on behalf of the medical council. Renewal of registration will be linked withcontinuing medical education (CME) programs which doctors will have to undertakeperiodically in order to update their medical knowledge and skills. It will be the responsibilityof the local health authority, through a mandate from the medical councils, to assure that
nobody without a license and a valid registration practices medicine and that minimumstandards laid down are strictly maintained.Managing the Health Care SystemFor every 3 to 5 units of 50,000 population, that is 150,000 to 250,000 population, a healthdistrict should be constituted (Taluka or Block level). This will be under a local healthauthority that will comprise of a committee including political leaders, health bureaucracy,and representatives of consumer/social action groups, ordinary citizens and providers. Thehealth authority will have its secretariat whose job will be to administer the health care systemof its area under the supervision of the committee. It will monitor the general working of thesystem, disburse funds, generate local fund commitments, attend to grievances, providelicensing and registration services to doctors and other health workers, accredit healthfacilities, implement CME programs in collaboration with professional associations, assurethat minimum standards of medical practice and hospital services are maintained, facilitateregulation and social audit, etc. The health authority will be an autonomous body under theoversight of the State Health Department. The FMP appointments and their family lists willbe the responsibility of the local health authority. The FMPs may either be employed on asalary or be contracted in on a capitation fee basis to provide specified services to the personson their list. Similarly, the first level hospitals, either state owned or contracted in privatehospitals, will function under the supervision of the local health authority with global budgets.The overall coordination, monitoring and canalization of funds will be vested in a NationalHealth Authority. The NHA will function in effect as a monopoly buyer of health servicesand a national regulation coordination agency. It will negotiate fee schedules with doctorsand hospital associations, determine standards and norms for medical practice and hospitalcare, and maintain and supervise an audit and monitoring system. It will also have theresponsibility and authority to pool resources for the organized healthcare system usingvarious mechanisms of tax revenues, pay roll deductions, social and national insurance funds,health cess, etc.The Panchayat Raj institution at the Block level can be used as the fulcrum around which thehealth district is built. The local health authority should derive its membership from amongstpanchayat representatives, providers, health department officials and civil societyrepresentatives in equal numbers and this should be the key planning, decision-making andimplementing agency, including for determining budgets and expenditures. The role of thenational and state authorities should be one of oversight and for provision of appropriateresources. The rest should be left to the local health authority. The National Rural HealthMission offers an opportunity for decentralized management of the healthcare system bycreating agencies like district and block management units – these should constitute thesecretariat of the local health authorities and not be program management units as envisagedunder NRHM. We have to outgrow the program mode of functioning and look at healthcarefrom the perspective of comprehensive services delivered universally. In fact the NRHMclearly articulates the need for architectural correction. (MoHFW 2005) Such restructuringwill be possible only if: The healthcare system, both public and private, is organized under a common umbrella/framework as discussed above
The financing mechanism of healthcare is pooled and coordinated by a single-payer system Access to healthcare is organized under a common system which all persons are able to access without any barriers Public finance of healthcare is the predominant source of financing The providers of healthcare services have reasonable autonomy in managing the provision of services The decision-making and planning of health services is decentralized within a local governance framework The healthcare system is subject to continuous public/community monitoring and social audit under a regulated mechanism which leads to accountability across all stakeholders involvedThe NRHM Framework (MoHFW 2006) one way or another tries to address the above issuesbut has failed to come up with a strategy which could accomplish such an architecturalcorrection. The framework only facilitates a smoother flow of resources to the lower levelsand calls for involvement of local governance structures like panchayat raj institutions inplanning and decision making. But the modalities of this interface have not been worked outand hence the local government involvement is only peripheral.In order to accomplish the restructuring that we are talking about the following modalitiesamong others need to be in place: All resources, financial and human, should be transferred to the local authority of the Health District (Block panchayat) The health district will work out a detailed plan which is based on local needs and aspirations and is evidence based within the framework already worked out under NRHM with appropriate modifications The private health sector of the district will have to be brought on board as they will form an integral part of restructuring of the healthcare system An appropriate regulatory and accreditation mechanism which will facilitate the inclusion of the private health sector under the universal access healthcare mechanism will have to be worked out Private health services, wherever needed, both ambulatory (FMP) and hospital, will have to be contracted in and appropriate norms and modalities, including payment mechanisms and protocols for practice, will have to be worked out Undertaking detailed bottom-up planning and budgeting and allocating resources appropriately to different institutions/providers (current budget levels being inadequate new resources will also have to be raised) Training of all stakeholders to understand and become part of the restructuring process Developing a monitoring and audit mechanism and training key players to do itThe implementation of the above process would be critically dependent first on the state andcentral government agreeing to changing the financing mechanism and giving completeautonomy to local health authorities and health institutions as envisaged above. This of coursewould need appropriate legislation. With the financing mechanism in place the local healthauthorities would require appropriate capacity building to manage the restructuring of the
healthcare system. The private health providers and their associations will have to be broughton board through discussions and explaining them the benefits of joining such a system andshould be involved in the process from the planning stage. Those serving in public healthinstitutions will have to be trained and informed appropriately to manage and run such ahealth system. And above all those in local governance bodies and civil society groups willhave to be oriented and skilled to planning, monitoring and auditing the functioning of such ahealthcare system.Such restructuring is difficult to undertake across the board immediately and hence initiallythe states can begin this process in a few districts with technical assistance from experts whowould be associated with the National and State Health Systems Resource Centres which arebeing/have been created under NRHM.