Recently, a national daily carried the eye-catching caption, “India ranks lower than even Nepal.” The reference was to India’s low rank in the Social Progress Index, especially in regard to health care. The paradox is that while India is “shining” in some favoured aspects of health care, we fall short in the delivery of dependable basic health care which should be available to all. This missing feature is referred to as Universal Health Coverage (UHC).
Why do we fail in UHC? Is a remedy beyond our reach?
With our booming medical industry, burgeoning corporate hospitals, spurt in commercial medical education and multiplication of AIIMSs, our progress at the high end of medicine is lauded but our concurrent poverty in UHC is ignored. As medicine has advanced worldwide, the health care system has become a pyramid with a narrow apex of tertiary care, a middle level of secondary care and a broad base of what is now called primary health care. As countries “developed”, there was a natural preference for the higher levels of the evolving pyramid. But some nations like the UK soon recognised that UHC cannot be achieved unless the base of primary care was deliberately strengthened and they are the leaders in UHC. We in India have failed to learn from them to give deliberate preferential attention to primary care. This policy paralysis is the underlying cause of our low ranking in UHC.
These countries also recognised the demanding role of primary care physician can’t be left to the “basic” graduate. And they developed institutions, like the Royal College of GPs in the UK, to lay down standards and offer postgraduate qualifications in primary care. Dependable, well-trained physicians are fundamental to primary health, especially in our fraught circumstances. In India, the budding specialty for primary care is known as family medicine (FM), its practitioners are family physicians and the unit of primary care is the Primary Health Centre (PHC) serving a population of 30,000. About 27,000 doctors are needed in primary care.
Filling the vacancies, even with raw graduates, has proved intractable even in states like Kerala and Tamil Nadu. If so, can we realistically hope to train and retain FM specialists in all PHCs? Let us consider the affordability first. Even if 30,000 PHC doctors were to be offered an inflated annual remuneration of `20 lakh each, the additional cost will be about `4,000 crore a year. In the long run, the reduction in morbidity, greater productivity and the decline of avoidable catastrophic illnesses will pay for this. In the interim, can we forgo the tax deduction allowed on premiums paid for commercial health insurance policies and divert the saving to this purpose? Suffice it to say that where there is political will, there can be a way.
Can we speedily train about 30,000 PHC doctors in FM? The Christian Medical College Vellore has evolved a set of two-year diploma courses in FM in the distance education mode, including on-site skills training. It has trained over 2,000. Bihar, Chhattisgarh, Orissa and Tamil Nadu have integrated the courses in their health care systems. Based on this programme, the Tamil Nadu Medical University is offering a master’s degree in medicine (FM) with 250 seats. Clearly, a crash course to upgrade FM skills of PHC doctors in required numbers is practicable at a national level.
This prioritisation of primary care has to be paralleled by similar changes in medical education. Departments of FM must be mandatory in colleges, practise FM at its best to demonstrate it to students and produce the highest quality of FM specialists. Highly skilled MDs in FM could also relieve the shortage of specialists at the secondary level. Such an initiative can change the face of primary and secondary care in 10 years.
For this it will be necessary to restructure the governing body (Medical Council of India) to serve patients better and facilitate achievement of UHC. But that will have to be an exercise similar to the revolutionary Obamacare in the US.
The basic goal should be excellence in primary care delivered under a trained family physician. It can be done by the state with the Centre lending a hand by reorienting medical education. In fact, state governments can achieve much on their own by activist policies both in the service and educational sectors. The author was on the faculty of the CMC, Vellore. p_zachariah@hotmail.com