An overcrowded hospital in Delhi. Several illnesses could be taken care of in rural areas if PHCs and sub-centres worked
PHCs and sub-centres aren’t easy to upgrade
Ketki Shah and Nerges Mistry
Since the days of the Bhore Committee Report of 1948, the public health community in India has vociferously advocated a comprehensive primary healthcare system. The National Health Policy of 2017 finally acknowledges the importance of such a strategy.
The new policy has identified the establishment of Health and Wellness Centres (HWCs) as the preferred way to deliver universal free comprehensive primary healthcare. Upgrading sub-centres and re-orienting Primary Health Centres (PHCs) to develop into HWCs was articulated by Finance Minister Arun Jaitley in his Budget speech of 2017-18 which committed to developing 150,000 HWCs in the country.
The HWC is also linked to the recently initiated non-communicable disease (NCD) programme which will initially tackle Type 2 diabetes mellitus, hypertension, cervical, breast and oral cancer and subsequently chronic obstructive pulmonary disorder (COPD). The Goliath issue of mental health is included. To tackle all of these, as well as the omnipresent Maternal and Child Health (MCH) programme at the 5,000 population level, the health centre is to be staffed with a mid-level provider (an AYUSH doctor), a public health nurse and a male multipurpose worker.
One key concept is that each family will be registered with the HWC. The primary healthcare team will be responsible for the health of its population. As a norm, the mandate of the new HWCs is to survey the local population, undertake primary clinical examinations/investigations and refer patients to higher levels of care. This will hopefully be combined with community awareness activities.
Though this initial part is clearly defined, relatively less is said about follow-up, important for chronic diseases. Setting up HWCs without strengthening referral centres and follow-up processes would lead to major hindrances in providing comprehensive primary healthcare.
This provision of comprehensive care will require additional skill building, continued supply of drugs and other items, effective information systems and a responsive referral system.
Introducing NCDs into the public healthcare system is being done on a district-wise basis. Around 109 districts have been identified in the first phase. An additional 109 will be included after two years. All districts of India will be covered in the third phase.
Training modules for primary care workers (ASHAs, ANMs), Medical Officers (MOs) and staff nurses are also nearly complete. A group of national-level trainees has been trained in the delivery of training modules at the central level and partially at the state level.
The rolling out of the NCD programme is highly ambitious on the part of the Health Ministry and one that is much needed in view of the NCD epidemics which India suffers from. However, are our needs matched by commensurate potential and preparedness?
Synergy and messaging
Despite such strong government commitment and assuming that additional financial resources are being made available, what are the desirable effects we hope to achieve? Have we created benchmarks? Further, benchmarks cannot be achieved unless ancillary steps are taken in environmental controls, urban planning, food security, water safety, social welfare programmes, employment, and so on.
The control of NCDs cannot rely on biomedical models that are upward-expanding expense spirals. Ancillary programmes need to be linked to action at community level, an important element of which is behaviour change communication that factors in poor literacy and wrongly entrenched nutritional practices. Innovative messaging, based on sound research that would create awareness and change lifestyles, are required.
The government’s ambitious plan of converting 150,000 sub-centres into HWCs would require strong financial commitment. However, there was just a nominal increase in the health budget of 2017-18 with no allocation specified for the HWCs. According to WHO estimates, to reach even two-thirds of the Sustainable Development Goals by 2030, an investment of 6.5 percent of GDP is needed. However, in India, public spending on health has remained stagnant at 1 percent of the GDP with minor fluctuations.
Many commitments have been made by the government to increase health expenditure. With the introduction of the National Rural Health Mission (NRHM) in 2005, India had envisioned an increase in public health expenditure to 2-3 percent of GDP by 2012. The Planning Commission had also committed to increasing public health expenditure to 2.5 percent of GDP by 2017.
The recent National Health Policy passed by the Cabinet has now furthered the timeline to attain this goal to 2025. The government has continuously failed to reach its target of increasing health expenditure.
With the current investment, will the government reach its target of upgrading 150,000 HWCs? Or will this scheme also sink into oblivion due to lack of adequate funds?
Training and personnel
Human resource capacity at the grassroots is a major challenge currently. Training institutions for ANMs who, till now, are manning sub-centres, are grossly inferior and understaffed with no standardised training material.
The ANMs role as MPWs (Multipurpose Health Workers) is clear but inputs during training are mismatched with what they are expected to deliver beyond mother and child health. The current training programme does not equip the ANM with the skills to provide comprehensive primary healthcare. Additionally, if primary healthcare workers are to serve as “wellness” workers, their abilities to implement preventive strategies like behaviour change need to be strong. Communication skills and counselling are major gaps in their pre- and in-service training. The lack of a clear description of job responsibilities worsens the problem.
In-service training has its own dilemmas – time constraints, logistics, training material and pedagogy. A strong case exists for strengthening pre-service training by investing in quality education and innovative strategies to promote self-learning. Pre-service training should be supplemented by continuously orienting health workers on their changing roles. For continuing education and even for referral and follow-up, telecommunications using models like ECHO (Extension for Community Health Outcome) could be gainfully applied.
The second question is whether we are adequately staffed. The health sector, since 1947, has never drawn up a blueprint for human resources needed by it. Numerous studies have highlighted the issues of manpower shortages and the unequal distribution of health workers.
Another major challenge is supportive supervision. In India, supervision tends to be authoritarian, control-based and limited to fault-finding. This focus has to change to improving performance and building relationships by helping to resolve problems and through positive feedback. Supportive supervision is essential to re-orient the skill sets of health workers to provide comprehensive primary healthcare.
Another overlooked gap is of skilled laboratory technicians. They are needed for numerous investigations to diagnose NCDs and for follow-up. The source of their training is vague and there are hardly any reports that vouch for their expertise and quality except perhaps in the field of tuberculosis and HIV. For NCDs, which rely on laboratory investigations, the importance of lab technicians cannot be overemphasised. Basic minimum qualifications need to be set for laboratory technicians placed at different levels of the system. This can only be done when it is decided which tests need to be undertaken at primary, secondary and tertiary levels. A white paper on strengthening of laboratories should also be prepared to address gaps in infrastructure, skills and analysis to meet the requirements of necessary investigations.
Transport, equipment and drugs
Currently, depending on the location, ANMs serve populations ranging from 5,000 to 30,000. Unless the worker-population ratios of the HWCs are rationalised, taking into account terrain, transport and the health conditions to be covered, there will be major gaps in service delivery and quality. Providing an NCD service would require visits to peripheral communities for monitoring and follow-up. Health care workers will need efficient transport facilities.
They would also require service equipment, much of which would need calibration and maintenance to adhere to quality requirements. There is a Biomedical Equipment Maintenance Programme in place but there is no feedback on its functionality and efficacy. Knowledge and requirement of equipment maintenance among primary healthcare workers is also perceived to be poor. Both these issues are at the heart of achieving correct diagnosis.
Procurement of items like gluco-strips or lancets is paramount for seamless activity of the HWCs. An efficient and proactive procurement system is therefore a necessity for post-survey activities, the lack of which would pose an ethical dilemma. One way to ensure procurement efficacy is to make sure that HWC staff are well-trained in logistics and stocktaking. However, central supply pools need to be responsive to peripheral shortfalls. Unfortunately, this has been the weakest point of the public health system. A study carried out by Marathe and Yakkundi (2017) in Maharashtra showed that despite the implementation of e-aushadhi, there has been no significant improvement in inventory management. It also noted the findings of the Directorate of Health Services (DHS) that only 40 percent of medicines indented by PHCs were supplied to them.
As per the policy on NCDs, treatment will be carried out at PHC or at the district/block level hospital. For patients who do get stabilised as a result, it may be helpful for HWCs to be stocked with follow-up medication. This would minimise the inconvenience of travel for patients and encourage better adherence and treatment control. Therefore, the inclusion of a mid-level provider in the HWC team would be a helpful addition and bolster HWC capacity. If such a proximal treatment policy were to come about, maintenance of adequate drug stocks would be a mandatory requirement for prevention of treatment interruptions.
No data, locally
The current health information system suffers from maladies such as inadequate data and use of information. The HMIS system is fragmented into different systems for different programmes and diseases with little interaction between them. This results in duplication of effort, wastage of time and data overload. ANMs spend significant time in documentation and reporting though much of it is not in real time. A study found that two-thirds of the ANMs’ time was spent on maintaining records. The data collected by the ANM is only used for reporting. It is seldom used by health workers to improve service delivery or local decision-making. This is because data is consolidated centrally and that makes it too late to be useful at local level. Feedback of data to primary healthcare workers is also not part of supportive supervision. Therefore, they see no value in data collection. Additional recording and reporting formats for HWCs without integrating with the current system would create another layer of work for the ANMs.
Need for health cadres
A future roadmap would need to inculcate learning from the 109 districts where the HWC and NCD programmes are currently unfolding. Such an assessment could be undertaken by the National Health Systems Resource Centre (NHSRC) and the ICMR to ensure quality and prevent duplication.
Pre-service training, especially for ANMs and ancillary cadres, must get the highest priority to cope with the complexities of multi-tasking. As more conditions like mental health, disabilities and other forms of cancer as well as trauma are added to the comprehensive healthcare package, knowledge and skill gaps of healthcare workers are likely to increase. The training programme should also focus on developing the right attitude to deliver primary healthcare.
Perhaps reliance on the existing cadres alone to tackle the breadth of disease at primary level is not wise. Either we completely restructure the existing public health nursing and ANM cadres into subspecialties that can serve as paramedical cadres, for example, dental hygienists, optometrists, palliative care, counsellors and so on, or we create separate paramedical cadres who can service areas based on local epidemiology. Mid-level skill building in prevention and curative care will reduce the load on higher-level health facilities and can even be perceived as a preventative area for curbing the severity of diseases and their complications.
Ketki Shah is a public health researcher with the Foundation for Medical Research, Mumbai Nerges Mistry is Director, Foundation for Research in Community Health, Pune