You are currently viewing Strategy for New India at 75:Inclusion-Comprehensive Primary Health Care

Strategy for New India at 75:Inclusion-Comprehensive Primary Health Care

  • On 15th August 2022, independent India will turn 75. In the lifespan of nations, India is still young. The best is surely yet to come. India’s youthful and aspirational population deserves a rapid transformation of the economy, which can deliver double-digit growth, jobs and prosperity to all.
  • The purpose of this, ‘Strategy for New India @ 75’, is to define clear objectives for 2022-23 in a  diverse range of 41 areas that recognize the progress already made; and challenges that remain; identify binding constraints in specific sectors; and suggest the way forward for achieving the stated objectives. 
  • The Strategy document has disaggregated the 41 sectors under four sections: drivers, infrastructure,  inclusion, and governance. 
  • The first section on drivers focuses on the engines of economic performance – in macroeconomic terms with chapters on growth and employment.
  • The section also discusses strategies for the doubling of farmers’ incomes; boosting Make in India; upgrading the science, technology and innovation ecosystem; and promoting sunrise sectors like fintech and tourism.
  • An annual rate of growth of 9 per cent by 2022-23 is essential for generating sufficient jobs and achieving prosperity for all. Four key steps, among others, have been spelled out for achieving this GDP growth rate. These are:

a. Increase the investment rate as measured by gross fixed capital formation (GFCF) from present 29 per cent to 36 per cent of GDP by 2022. About half of this increase must come from public investment which is slated to increase from 4 per cent to 7 per cent of GDP. Government savings have to move into positive territory. This sharp increase in the investment-to-GDP ratio will require significantly higher resource mobilization efforts as elaborated in the chapter on Growth.

b. In agriculture, emphasis must shift to converting farmers to ‘agripreneurs’ by further expanding e-National Agriculture Markets (e-NAMs) and replacing the Agricultural Produce Marketing Committee  (APMC) Act with the Agricultural Produce and Livestock Marketing (APLM) Act. The creation of a unified national market, a freer export regime and the abolition of the Essential Commodities Act are essential for boosting agricultural growth.

c. A strong push would be given to `Zero Budget Natural Farming (ZBNF) techniques that reduce costs,  improve land quality and increase farmers’ incomes. This is a tested method for putting environmental carbon back into the land. Therefore, ZBNF allows India to significantly contribute to reducing the global carbon footprint.

d. To ensure maximum employment creation, codification of labour laws must be completed and a massive effort must be made to upscale apprenticeships.

  • The second section on infrastructure deals with the physical foundations of growth. A lot of progress has been made across all infrastructure sectors. This is crucial to enhancing the competitiveness of Indian business as also ensuring the citizens’ ease of living. Three key steps, among others, are:

a. Expediting the establishment of the Rail Development Authority (RDA), which is already approved. RDA  will advise or make informed decisions on an integrated, transparent and dynamic pricing mechanism for the railways. Investment in railways will be ramped up, including by monetising existing railway assets.

b. The share of freight transported by coastal shipping and inland waterways will be doubled. Initially,  viability gap funding will be provided until the infrastructure is fully developed. An IT-enabled platform would be developed for integrating different modes of transport and promoting multi-modal and digitised mobility.

c. With the completion of the Bharat Net programme in 2019, all 2.5 lakh gram panchayats will be digitally connected. In the next phase the last mile connectivity to the individual villages will be completed. The aim will be to deliver all government services at the state, district, and gram panchayat level digitally by  2022-23, thereby eliminating the digital divide.

  • The section on inclusion deals with the urgent task of investing in the capabilities of all of India’s citizens. The three themes in this section revolve around the various dimensions of health, education and mainstreaming of traditionally marginalized sections of the population. While there are multiple dimensions and pathways  contained in the chapters in this section, four key steps, among others, are:

a. Successfully implementing the Ayushman Bharat programme including the establishment of 150,000  health and wellness centres across the country, and rolling out the Pradhan Mantri Jan Arogya  Abhiyaan.

b. Upgrading the quality of the school education system and skills, including the creation of a new innovation ecosystem at the ground level by establishing at least 10,000 Atal Tinkering Labs by 2020.

c. As already done in rural areas, affordable housing in urban areas will be given a huge push to improve workers’ living conditions and ensure equity while providing a strong impetus to economic growth.

d. Implementing strategies to achieve regional equity by focusing on the North-East region and successfully rolling out the Aspirational Districts Programme.

  • The final section on governance delves deep into how the tasks/business of government can be streamlined and reformed to achieve better outcomes. It involves a sharp focus on ensuring accountability and a shift to performance-based evaluation.
  • The government will revamp its data systems and analysis so that all policy interventions and decision-making are based on evidence and real-time data. This will yield efficient and

targeted delivery of services and justice to those who need them the most.

  • Three key steps, among others, are:

a. Implementing the recommendations of the Second Administrative Reforms Commission as a prelude to appointing a successor for designing reforms in the changing context of emerging technologies and the growing complexity of the economy.

b. A new autonomous body, viz., the Arbitration Council of India, may be set up to grade arbitral institutions and accredit arbitrators to make the arbitration process cost-effective and speedy, and to pre-empt the need for court intervention.

c. The scope of the Swachh Bharat Mission may be expanded to cover initiatives for landfills, plastic waste and municipal waste and generating wealth from waste.

  • To achieve the goals of New India in 2022-23, it is important for the private sector, civil society and even individuals to draw up their own strategies to complement and supplement the steps the government intends to take. With the available tools of 21st-century technology, it should be possible to truly create a mass movement for development. With the Sankalp of all Indians, India will have Siddhi.

Check out our previous blogs on the Strategy for New India at 75:

Objectives

Under Ayushman Bharat, scale-up a new vision for comprehensive primary health care across

the country, built on the platform of health and wellness centres (HWCs), to:

  • Provide quality ambulatory services for an inclusive package of diagnostic, curative, rehabilitative and palliative care, close to the people.
  • Deliver preventive and promotion services, and action on the ground to tackle determinants of ill health locally.
  • Create a mass movement for Healthy India (Swasth Bharat Jan Andolan).

Current Situation

  • Primary health care is a key enabler for higher life expectancy, better health outcomes and lower costs for the nation. Primary health interventions help detect diseases early, well before complications set in, thus pre-empting the need for secondary and tertiary care.
  • Developed nations such as the UK, Australia, Canada, Netherlands and Sweden spend a large share of their federal healthcare budgets on primary care.
  • In India, primary care infrastructure exists as a network of sub-centers, primary health centres and community health centres. However, the focus of services has remained narrow – largely prioritized around reproductive, maternal and child healthcare, and some communicable diseases (notably, malaria). The battle against non-communicable diseases can only be won through a primary health system that ensures that chronic diseases are not only detected early but also that preventive action is taken to ensure improved lifestyles.
  • The National Health Policy (NHP), 2017, envisages comprehensive primary health care delivered through HWCs. The policy also commits that two-thirds or more of government spending will be targeted at primary care. Additionally, the announcement of Ayushman Bharat by the government is a game-changer.

Constraints

  1. The existing primary health care model in the country is limited in scope. Even where there is a well-functioning public primary health centre, only services related to pregnancy care, limited childcare and certain services related to national health programmes are provided, which represent only 15 per cent of all morbidities for which people seek care.
  2. The conversion of 150,000 sub-centers into HWCs was announced in the budget speech in 2017 and was enshrined in the NHP, 2017. Although less than 4000 such centres were sanctioned in 2017-18, the government is committed to accelerating the pace of sanctioning and putting up HWCs to meet the target in good time.
  3. Supply-side deficiencies, poor management skills and lack of appropriate training and supportive supervision for health workers prevent delivery of the desired quality of health services.
  4. A primary health care model for the growing urban population has not been conceptualized, notwithstanding a few assorted initiatives by some states.
  5. Although the National Health Mission focuses on engaging communities through village health, nutrition and sanitation societies, health has not yet become a people’s movement.
  6. Funding for health is inadequate, leading to low spending on primary care.
  7. Citizens have to incur high out-of-pocket expenditure on primary health care, of which the largest expenditure is on drugs.
  8. There is a shortage of adequately trained and motivated personnel.

Way Forward

  1. Accelerate the establishment of a network of 150,000 HWCs
  • Operationalize a network of 150,000 HWCs on priority by 2022-23 in order to ensure sufficient coverage of affordable primary care and lower the burden on secondary and tertiary care.
  • HWCs should provide services such as screening and management of non-communicable diseases; screening and basic management of mental health ailments; care for common ophthalmic and ENT problems; basic dental health care; geriatric and palliative health care, and trauma care and emergency care.
  • These are in addition to the existing requirement for primary care services related to reproductive and child health, adolescent health, and selected communicable diseases covered by national health programmes.
  • The key features of New India’s primary health care system will be:

O A primary health care nucleus comprising five to six upgraded sub-centers coupled with a primary health centre, and population outreach.

O A team led by a mid-level health service provider, auxiliary nurse midwives (ANMs),

accredited social health activists (ASHAs) and a male health worker responsible for comprehensive primary health care services for a population of about 5,000.

O Planning of health facility distribution in districts to ensure that a continuum of care is available on the principles of ‘time to care’ through a strong referral linkage.

O Digitization of family records and information from the community to the facility level.

O Use of real-time data to guide public health action and implementation monitoring.

O The HWCs would act as the ‘gateway’ for access to secondary and tertiary health services.

  1. Enable mechanisms for rapid scale-up
  • Put in place the following workstreams to create 150,000 well-functioning HWCs across the country – infrastructure; human resources (mid-level professional recruitment, training and deployment; deployment and orientation of ANMs and male health workers); an Information and Communication Technology (ICT) system; supply chain for drugs and disposables; clinical and public health protocols and tools; managerial/supervisory processes, and monitoring, evaluation and accountability systems.
  • Under Ayushman Bharat, put in place the necessary institutional mechanisms with a focus on health and wellness at the central and state levels for effective, timely and robust system-level implementation as well as strong engagement with departments/directorates of health in the states.
  • Establish special national and state-level task forces and ‘command centers’.
  • Create mechanisms for rapid scaling up of training.
  • Develop empowered governance mechanisms for efficient decision-making, coordination, funds flow, procurement, contracting, recruitment, construction, and implementation.
  • Mobilize Corporate Social Responsibility (CSR) and Non-Resident Indians for funding HWCs.
  • Some HWCs could also be mobile, particularly for better access to remote communities.
  1. Coordinate action for disease prevention and public health promotion and address social determinants of health
  • Provide preventive services to improve healthy behaviours for family health and control the incidence of communicable and non-communicable diseases among the population covered by HWCs.
  • Facilitate partnerships between HWC teams and other frontline development teams (nutrition, education, Swachh Bharat, etc.) to engage with communities to address the socio-cultural and environmental determinants of ill health at the local level.
  1. Catalyse people’s participation for healthy India: Swasth Bharat Jan Andolan
  • Mandate and motivate HWC teams to work closely with village health, sanitation and nutrition societies, Panchayati raj institutions as well as all other constituents of civil society in rural and urban spaces. This is vital because people are not just targets of health services but partners and multipliers of health-related activities.
  1. Emphasise concurrent learning, operations research and innovation
  • Undertake a well-funded research programme to find the best pathways for effective and context-specific scaling up of primary health care. This is critical because it is well-known that a single model of primary health care may not work for all districts/states in the country.
  • Conduct research to assess the population-level health impact of the programme and its effects on out-of-pocket expenses.
  • Develop urban adaptations of comprehensive primary care