Preventive, promotive and primary healthcare needs to become priorities in our investment

Shrirupa Sengupta, Director, Swasti-The Health Catalyst emphasises that there are still several communities in India who are at the last mile with little or no access to our public health system. Preventive, promotive and primary healthcare needs to become priorities in our investment

Overall, there is a much-needed increase in allocations for public health system strengthening, the major National Health Mission programme, COVID related provisions, services for women and children, mental health programme. Digital models are attractive but investment in digital literacy is important. Climate change and its effects on health of our citizens is a reality. More and more people are reporting NCDs and chronic obstructive pulmonary diseases. Preventive health and promoting better nutrition is going to be critical – especially for the next generation. Investments in wastewater surveillance for pandemic and public health planning to increase allocative efficiencies is critical at this juncture.

Let’s start at the basics. Primary, preventive and promotive health

Our work in public health is quite clear as the new budget season arrives. As public health workers, our exposure, experience and expertise has contributed to both to our understanding of the availability of primary health care in India as well as the quality of work that primary care providers are able to make available for the most vulnerable populations.

If there is one thing that India has – it is the unfathomably large network of brick and mortar primary health centres (PHCs) and sub-centres. Additional to this are the private enterprises (often referred to as Community Health Centres), mobile vans and traveling health camps – approaches that the Ministry of Health and Family Welfare adopt across their several program verticals and campaigns.

The brick and mortar primary health centres are each supposed to serve a population of 25,000. In addition to this, the National Health Mission envisaged one Sub-centre established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas – the application of the same is subject to local needs and terrain. The health sub-centre, as defined by the National Health Mission is the most peripheral and first contact point between the primary health care system and the community.

Despite this seemingly fool proof framework, the picture on ground still requires attention.

Sadly, in many poor states, such as Madhya Pradesh, Bihar and Jharkhand, a PHC covers as many as 45,000, 49,000 and 76,000 people. And while tele-medicine / tele-health is an approach that the Government of India is keen on – the digital divide persists. And, the current location of PHCs is also not too helpful. Let us take for example In Rajasthan, the population is often so dispersed (especially in hilly areas in the south and in the desert in the west) that a family may need to travel 10-20 km to reach the nearest health centre.

Perhaps this year is the time to map the current coverage of PHCs as well as the sub-centres, along with community health centres as well as tele-health options and be pragmatic about making this jigsaw puzzle of taking health to the last mile work. All the while keeping in mind the reality of the digital divide and the hurdles of rural transport. At present under all the plans of Government of India, the PHCs are expected to deliver centrally designed, targeted vertical programs. While from a clinical perspective this may be a great logic map, it ends up alienating PHCs further from communities and this may be the right time to rethink the PHC framework also in line of how health and wellbeing is partnered between the communities at the last mile and the primary health care system.

But would geo-locational mapping and rethinking PHCs actually solve the problem? Not really and here is where human resources for health makes an appearance.

Just looking at PHCs, we see the shortfall in doctors. Something that reared its ugly head during the COVID-19 pandemic as well and needs to be addressed immediately. We understand that there are around 9,000 doctors in about 25,000 PHCs in the country, and about 2,000 of these PHCs have no doctors. In many others, a single doctor is posted for care round the clock, 365 days a year.

Given this reality and the intensive work that our doctors undertake, one can well understand the issue of quality that is sure to crop up. Add to it that while globally there is a movement towards nurses taking the lead of primary, promotive and preventive care, at India we are both understaffed in nursing as well as uncomfortable about nurses taking the lead – be it from a medico-legal point of view or from social norms and acceptance. It also does not help that our ANMs (Auxillary Nurse and Midwives) end up being the single point of contact for multiple programs with little or no increments in incentives and human resource support at the last mile.

Most vacancies for doctors are in tribal and other similarly underserved areas.

In our structure, the management of PHCs along with curative care are both dependent on physicians. Therefore no doctors means that many PHCs end up badly managed and badly equipped to provide any sort of quality care even if the same is undertaken by a nurse or a visiting doctor.

Of the 709 PHCs surveyed in 2009 by the International Institute for Population Sciences, Mumbai, about 24 per cent did not have an electricity connection and 63 per cent did not have piped water supply.

And here is where it hurts the backbone of the public health system. When there is under investment in primary health care and in PHCs, the PHCs end up being defunct/nearly defunct entities that are under equipped and lacking in drugs and supplies that can provide comprehensive primary care. Comprehensive primary care – the dream of Ayushman Bharat is critical for improved wellbeing of the Indian population – be it as a protecting factor from long COVID or for a more accomplished and successful populace that drives the Indian GDP and makes India a developed country by 2047.

While we are on human resources for health, it is worth deliberating on the distribution of health workforce in India.

It is well understood that medical students and fresh medical school graduates are compulsorily deployed in semi-urban and rural areas to serve underserved communities. However, this does not solve the long standing problem of the skewed distribution of health workforce across states and rural–urban settings.

Nearly two-thirds of all health workforce in India is concentrated in urban areas. This leaves the rural population with undiagnosed non-communicable diseases that shortens life span and plunges downward their quality of life. Most of our rural populace arrive at medical establishments in urban areas seeking health care when it is either too late.

Most unfortunately this travel is usually inter-state with most of the less developed states such as Bihar, Jharkhand, Odisha, Rajasthan, Uttar Pradesh, etc., reflecting the acute shortage of health workforce in both urban and rural areas.

When we look at the public and private health infrastructure – the majority of the doctors are employed in the private sector with nurses fairly equally distributed. When it comes to traditional medical practitioners – employment appears to be solely with the public sector which is understandable given the Ministry of AYUSH actively incorporating traditional medicine especially into the preventive and promotive aspects of healthcare.

However, this unequal distribution combined with the mandate of PHCs being managed and led by doctors ends up creating a catch 22 situation for the primary healthcare infrastructure – unequal mix of skills as well as no way to move forward to adapt innovative practices in public health settings to meet healthcare needs at the last mile.

Healthcare workers irrespective of where they are are battling significant stress factors causing severe situations of burnout and mental health challenges. It is critical to invest not only in the system but also in caring for our human resources for health care.

This is especially critical with the climate and health emergency at our doors.

We know by now that climate change poses the greatest threat to the world and disproportionately affects people and geographies that are most vulnerable. What is worse is that communities who have had least to do with the damage to our earth but are dependent on natural resources for livelihoods, such as smallholder farmers, artisanal fisherfolk, forest dwellers, indigenous people in tribal areas, are the most affected.

India’s commitments to climate change are ambitious and would require tremendous effort. For instance, our country’s commitment to increase non-fossil energy capacity to 500 GW requires us to more than triple our current capacity in the next 9 years.

We know that large-scale efforts to reduce India’s dependence on fossil fuels and its carbon emissions would improve air quality and have positive health impacts. However India’s increasing population and economic growth could be impediments to its commitment to reduce fossil fuel usage.

Thus, greater collaboration among the currently siloed sectors of climate change, air pollution, and public health is essential.

The current climate and health emergency also requires increased investment in the understanding and mitigation of climate related ailments such as Chronic Obstructive Pulmonary Disease (COPD).

As India starts on its COP26 commitments, it is prudent to prioritize regions with the worst health indicators and its various vulnerable communities to ensure that its health interventions contribute positively to its climate commitments.  The policy tools employed to achieve these commitments will require the health sector to reduce its own emissions as well. Consequently, greening hospitals and healthcare facilities are  emerging as an important aspect of the policy discourse and needing investment in this space.

COVID-19 reminded us the importance of being prepared. And it is no co-incidence the Bengaluru’s Wastewater Based Surveillance was born to respond to the COVID-19 pandemic.

The objective was to leverage Wastewater Based Epidemiology for monitoring and predicting disease outbreaks within the city. In keeping with its intent, it strived to create meaningful partnerships with experts working in a number of domains, ranging from public health, infectious disease and genetic epidemiology, microbiology, biostatistics, geospatialists, drainage and water system experts, and public health administration, who could help to build an authentic, robust and comprehensive systematic surveillance mechanism in Bengaluru.

It provided early warning insights on the spread of COVID-19 within the city. As a community-level surveillance and early warning system, WBE has the potential to inform evidence-based decision-making ahead of more normative measures of disease monitoring. It substantiates the existing knowledge base of disease epidemiology thus making it critical as a preventive mechanism for public health.

Through its advanced warning capabilities, it has the ability to alert other disease surveillance mechanisms about the impending threat and inform authorities about the need to maintain extra vigil whilst dealing with and reporting suspect cases. An investment in Wastewater Based Surveillance will be able to get India’s public health endeavour ahead of the curve in terms of knowing about and addressing everything from multi-drug resistant organisms to a potential disease outbreak.