View: Picking up fragments of the Indian healthcare system

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The Indian healthcare system can no longer remain fragmented. There needs to be a cohesive call to build back a more resilient health system with better capacity and interconnectedness.

View: Picking up fragments of the Indian healthcare system
Amidst the second COVID-19 wave, frantic cries for oxygen, hospital beds, medicine, and even a place to cremate their own, exposed the fragmented state of the Indian healthcare system.
Urban India, where private healthcare is widely accessible, has managed to counter the onslaught of COVID's second wave. But, rural India's threadbare public health systems is languishing under the burden of the ever-mutating virus! The true extent of the pandemic’s impact on the rural healthcare system is yet not truly known as most media, medical fraternity, and society-at-large continue to focus on the urban scenarios and talking about the possibility of the third wave.
To be fair, the healthcare system was already in dire need of reform long before the COVID-19 pandemic. The pandemic has just amplified the structural weaknesses in India's health system, ranging from lack of capital expenditure on health to inadequate medical infrastructure, supplies, and insufficient healthcare workers in public hospitals to profiteering by private hospitals. Now try and visualise the situation at a government Primary Health Care Center in a village! Near empty dilapidated building, no equipment, staff, medicines, nothing!
One of the first blueprints of the healthcare system in India, in the year 1946, emphasised that "No individual should fail to secure adequate medical care due to inability to pay." But the grand vision till date has not materialised. The last 75 years of inertia should now be galvanized to ensure that the country's collective suffering is translated into long-lasting change and can provide basic healthcare to all.
Investment in healthcare
India is among the countries with the lowest spending on healthcare in the world. While government spending on healthcare has almost doubled between 2015 and 2020, it is still low when compared with the other OECD countries and BRICS countries.
The pressure to combat COVID-19 is seeing rapid 'scale-up' in health services in states and by the center, with stop-gap arrangements, particularly concerning health infrastructure, drug procurements, and operationalizing digital platforms. But these are 'reactive' attempts to moderate an out-of-hand situation when the primary goal should never be to never let the country come to its knees as we all saw as a result of the second wave!
The newly announced Atma Nirbhar Swasth Bharat Yojana is a step in the right direction as it focuses on capital investment to set up much-needed healthcare centers, labs, oxygen manufacturing plants in each of the states, etc. Additional funds are also needed to strengthen social and preventative medicine research to support the country to build scientific evidence to strategize effectively.
Implementing community-based efforts
Primary Healthcare Centers (PHCs) are the first and, in most cases, the only access to medical support in rural and remote areas. PHCs are envisaged to provide integrated curative and preventive healthcare, but they battle shortages in infrastructure, workforce, equipment, drugs, and other logistical supplies.
PHCs can be helped by community-based efforts. For example, skilling Community Health Workers (CHWs) to consult and treat asymptomatic and mild COVID infections can prove effective. Further, the CHWs can also attend to cases of other mild diseases and infections, routine health check-ups and immunizations. This will reduce the burden on primary and secondary health care systems. There are already several innovative community-based health efforts in rural India that have had great results. For example, through the Link Workers Scheme, the National AIDS Control Organization has been able to slow down the incidence of HIV in India.
The additional support to community-based efforts will help the governments ensure the continuity of other essential services such as the Maternal, Newborn, and Child Health (MNCH) services even during difficult times.
Arming frontline workers
The voluntary workforce of poorly paid, semi-literate women is India's first line of defense against any local health crisis. The most depended upon Anganwadi and ASHA workers earn meager part-time salaries because they are considered part-time volunteers, although they work full-time due to local demands. During COVID, while they had additional duties, these members were not provided proper protective gear, protection against the stigma and backlash of communities, or extra income for their efforts. Several ASHA workers even protested across the country for their pending salaries. Frontline workers such as ASHA, ANMs, etc., should have increased salaries, have bonuses for achieving targets, etc., in addition to providing adequate protection gears, materials, and relevant technologies.
Incentivising medical personnel to work in rural areas
The distribution of doctors in India remains highly skewed towards urban areas and the private healthcare sector, while many vacancies persist in the government healthcare sector, particularly in rural areas. Lack of staff undermines various initiatives by the National Health Mission to strengthen and provide round-the-clock healthcare services and implementation of Indian Public Health Standards.
To encourage more doctors into the government healthcare sector, states and the center need to introduce a 'package' of incentives such as increased salary, enhanced opportunities, and recognition, better equipped and supplied health facilities, improved living conditions, etc. For example, the reservation in post-graduate education for rural medical practitioners proved to be effective in encouraging both—medical students and in-services doctors—to join the rural healthcare system.
Leveraging technology for preventative measures
The low availability of doctors can perhaps also be bridged through technological interventions as we already have evidenced that technology can help take preventive measures. According to NITI Aayog, India has officially recognised the need for telemedicine, given the large mobile phone-using population. Telemedicine can enhance the quality of care and bridge the gaps in healthcare services through services such as traditional dial-in audio helplines, emergency medical inquiry, health education. Nursing personnel and community health workers should be trained to run mobile teleconsultation centers and bridge the gap between rural patients and urban medical practitioners.
Preparing for the future
Science points to evidence that COVID will continue to be part of our future. Therefore, we need to build health systems that can help us cope so that even repeated outbreaks remain less painful and disruptive. Segregating health services will allow and secure essential services with a reduced risk of exposure to COVID, reducing the widespread fear among users and help healthcare providers strategise well.
The majority of public and private health facilities have been diverted towards COVID-19-related care, increasing health disparities by disrupting routine health services. There is a significant decrease in immunisations, institutional deliveries, inpatient and outpatient consultations for critical ailments. This will put a severe burden on India, which already bearing few of the highest global burdens of HIV, TB, infant and maternal mortality rates, anemia, malnutrition, to name a few.
The Indian healthcare system can no longer remain fragmented. There needs to be a cohesive call to build back a more resilient health system with better capacity and interconnectedness. Our health system needs to provide faith to society. We have to work towards a fairer health system that has explicit intentions to work towards a more inclusive and equitable society.
—The authors, Neelam Makhijani is CEO and Country Director, ChildFund India and Pratibha Pandey is Senior Specialist – Health, ChildFund India. Views expressed are personal

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