“Sub-optimal availability and accessibility to health facilities in rural and tribal areas and underutilization of established capacities in government / public sector have resulted in a skew towards private tertiary care in urban areas in India with unsatisfactory health outcomes.” HSD Srinivas, head of Tata Trusts’ Health portfolio, explains how the Trusts' 5-step framework tries to address the challenge
There’s a dichotomy that plagues the Indian healthcare sector. On the one hand, leading Indian metro cities have emerged as medical tourism hotspots, thanks to the development of super-speciality hospitals that provide cutting-edge tertiary healthcare. The quality of care and relative affordability of treatment makes our country a preferred healthcare destination for people from around the world. According to latest estimates, India recorded a total number of 6,40,000 overseas patients in 2019. On the other hand, rural India presents a very different and sombre picture, even for primary healthcare. Only 3% of India’s doctors live in rural areas, where 70% of India’s population is concentrated!
The World Health Organization has prescribed a doctor-patient ratio of 1:1000. In India, the ratio is 1:1456, at a time when there is a surge in disease burden due to the rise of non-communicable diseases (NCDs or lifestyle diseases) and communicable diseases.
By one estimate, about 80% of disease conditions can be addressed at the primary care level with a basic physician and community health worker. However, vast swathes of our population lack access to quality primary healthcare. This lack of accessibility increases the risk of already-vulnerable communities neglecting minor ailments and chronic diseases until they turn into acute conditions. The subsequent necessity for costly emergency care drains precious personal and national resources – pushing an estimated one million families below poverty level every year.
India is signatory to SDG goals 2030 and Universal Health Care Framework adopted by the UN General Assembly in 2019. In 2018, the Indian government launched the second leg of ‘Ayushman Bharat’, a programme aimed at improving primary care delivery significantly. This programme has mandated the creation of Health and Wellness Centres (HWCs) with the availability of appropriate diagnostics and drugs. It also involves extensive use of technology (such as apps for screening and management of NCDs).
The systems strengthening approach to improve access and availability of primary health care
The Tata Trusts’ initiatives in improving access to health care have acquired a new urgency during the Covid-19 pandemic. The systems framework that the Trusts have been employing includes:
1. Developing physical infrastructure and bettering ambience to improve utilisation:
The foremost need of communities in many rural and semi-urban parts of the country is to access trusted, credible primary care nearer to their homes. This can be made available through:
a) Telemedicine and Mobile Medical Units: These have emerged as an effective way to take primary healthcare services and specialist advice to the doorsteps of people in remote corners of the country. The telemedicine units have a well-equipped infrastructure and work on a hub-and-spoke model. Doctors based in a central hub, a parent hospital, consult patients virtually, facilitated by a trained nurse in remote locations where patients reside.
The mobile medical units have trained medical officers and nurses. Patients can access free consultations and point of care diagnostic tests besides regular prescriptions for a host of primary conditions at scheduled intervals of time.
Tata Trusts deployed this model in Mathura and Varanasi districts in UP, and Vijayawada in AP. Thirty-five telemedicine unit spokes connected to two doctors’ hubs and were supported by six mobile medical units. This translates into 500,000 medical consultations and screening, diagnosis, and on-going treatment of more than 100,000 individuals for NCDs such as diabetes, hypertension, and cancer. Besides, these hub-and-spoke models also provide necessary care for minor ailments that range from fevers to musculoskeletal disorders, etc.
b) Ambience management and structural reforms to existing PHCs and hospitals: Several PHCs in the country are in the need of modernisation and structural reforms. Improving the quality of PHC infrastructure is thus an important step towards bettering access and building confidence about accessing PHCs, which decreases the rush to tertiary hospitals for primary care.
Our PPP with Nagpur Municipal Corporation helped modernize 25 urban PHCs. Our advocacy of this model helped Chhattisgarh adopt a similar model to modernize over 20 UPHCs while the Government of Telangana has created over one hundred urban clinics. All this has resulted in increased utilisation of the same government facilities – in Nagpur, for instance, there was a 250% increase in utilisation.
At the 129-year-old Regional Mental Hospital in Nagpur, the Trusts have been working to address the critical needs of patients by building acute wards, washrooms, drinking water facilities and a salon. Tribal hospitals in Bilaspur, Bissumcuttack and Gadchiroli, supported by large grants from the Trusts, have created centres of excellence in India’s hinterland.
2. Building capacity of frontline workers:
A community health worker is perhaps the most important cog in the wheel of primary health services, Frontline workers are not just helpful in disease control, they can also be used effectively in spreading awareness and in the prevention of disease at the community level. Their role is indispensable. However, they need to be constantly reskilled and upskilled to meet the demands of the constantly changing healthcare scenario.
The Trusts are helping mentor and build the capacity of frontline workers in 29 states and 9 union territories. More than 60,000 health workers across the country have been trained in NCD detection and management through the Tata Trusts Pan India NCD programme. The programme aims to screen over 100 million Indians over the age of 30 for NCDs. Screening and management will be done for hypertension, diabetes and three cancers: oral, breast and cervical. Frontline workers have continued to play a critical role in making the programme a success. Any primary healthcare initiative for that matter can only be successful when frontline workers are trained and empowered.
Interventions like home-based neonatal care have contributed to fruitful learnings in RMNCH programmes in Eastern UP under the Mission Asha project.
3. Blending with the community to find customised solutions:
Malaria and acute encephalitis syndrome (AES) are almost endemic to certain geographies, such as South Odisha – the single largest contributor to malaria cases in India, and Uttar Pradesh. The communities in these areas are vulnerable and suffer from rampant morbidity and mortality arising out of these communicable diseases.
To prevent diseases from wiping out populations from these regions, it is extremely important to empower the community to own the responsibility of their environment and health. We need to understand their challenges and create solutions that can prevent disease and keep the community in good health.
The Trusts have been working in these geographies to counter the malaria and AES challenges through community awareness of environmental engineering for vector control. Accessible healthcare at the doorstep by mobile medical units also make a big difference.
Some of the key highlights of our interventions include helping with parasite control, vector control, spreading awareness, tracking and ensuring immunisation for AES, early detection and prompt referral of AES cases, etc. We also collaborate with important medical authorities at both private hospitals and in the public healthcare system to execute vector control strategies, and so on.
4. Increasing technology adoption in improving primary healthcare access:
From medical devices to patient records, and from screening data to assessing the impact of interventions and treatment, technology plays a pivotal role in improving primary healthcare access. Making the right kind of medical devices and hardware available, introducing smart digital platforms, and providing the right kind of technical training and expertise are essential in helping frontline workers and communities adopt technology for better health outcomes.
The Trusts have been using technology in various healthcare interventions to provide efficient health care to patients across the country, to improve the effectiveness of programmes, and to enhance health outcomes. Technology upgradation is an integral part of hospital infrastructure development initiatives undertaken by the Trusts.
ASMAN is an application that incorporates clinical decision support systems on a platform that utilises online and offline medical oversights for timely interventions in intrapartum and neonatal care. Health system strengthening efforts in Telangana have showcased the comprehensive healthcare model leveraging technology, with Care Coordination Centres being central to this effort. Over 1.1 million electronic health records (EHR) were created in Telangana, pushing the state to aggressively adopt telehealth to network over 60 HUB hospitals and 3000 PHCs.
5. Strengthening systems through research, data, partnerships and policy advocacy:
The Indian healthcare system faces enormous challenges that need to be constantly monitored through research and examined through data analysis. The resultant findings need to flow back to the system where policies are developed, for policies to be effective and the impact long-lasting.
Partnering with academic organisations that have the relevant scientific and technical know-how helps to build expertise within the healthcare system and improve access and outcomes. The Trusts have been working extensively in this area.
India accounts for one-fourth of the global burden of tuberculosis (TB). To eradicate and prevent the incidence of TB, the Trusts support research institutes such as ICMR for studies on various interventions in tuberculosis management. The Trusts have also seeded the India Health Fund to foster innovations to eliminate TB by 2025 and malaria by 2030 from India.
The Trusts have incubated the Health Systems Transformation Platform (HSTP), to be an enabler of state-level capacity to evaluate, redesign and strengthen healthcare systems. The not-for-profit HSTP partners with the prestigious Harvard TH Chan School of Public Health at Harvard University, USA. Besides these Trusts have working relationships with Institutions like Sri Chitra Institute Kerala, AIIMS Gorakhpur, AIIMS Nagpur, ILBS Delhi etc.