Re-envision primary health care

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By: Dr Vinay Aggarwal & Dr R V Asokan

Covid 19 has rewritten priorities in our national life. Health care has emerged as an important internal security issue. In fact, it has asserted itself to be on par with economics. An appropriate and adequate response is in order. Strengthening Public Health infrastructure and human resources as well as outreach is the priority. The disparity in capacity between states is a challenge. Primary Health Care reduces morbidity and mortality. The need to re-envision primary care cannot be overemphasised. It takes courage of different orders. The wellness centre concept was disruptive. Nevertheless, it is a non-starter for several reasons. It needs a qualitative overhaul. It is time to go back to the drawing board.

The path to wellness of a society or a nation should be tangible and defined. When we upscale wellness from a state of mental, physical and social well-being of an individual to a society or its people, it would require to be structured as clinical services, public health services with diligent cognizance of social determinants of health. Conceptualizing good Governance to attain wellness of a people could mean clubbing together of these services (clinical, public health and social determinants) under one roof for which the prudent move would be to create a separate independent Ministry as Ministry for Wellness. The focused aim for the said Ministry would not only be the invocation of wellness for all but also ensuring its outcome measurement in the form of measurable happiness index as a parameter for the same. This can genuinely revolutionize the Health of the nation. At least water, sanitation, and poverty alleviation should be clubbed with Health for the attainment of wellness of all the people in the society.

Primary Health Care is essentially the entry point ambulatory care. The steel frame laid down by the Bhore Committee 1946 consists of Primary Health Centres. The concept of Community Health Centres and District Hospitals as referral centres essentially facilitates accessibility. If India has to achieve Universal Health Coverage prioritisation of Primary Health Care is essential. If this has to translate into a reality substantial resources need to be allotted. The classic dilemma between prioritising Primary Care and the vertical programmes is reflected all along with our Five Year Plans. India is a signatory to the Alma Ata Declaration. The declaration included social determinants of health. The definition of Primary Health Care needs to be expanded.

Primary Health care received a boost with National Rural Health Mission in 2004 and the Panchayat Raj connect it attempted to bring in. These two initiatives were substantial and in the right direction. Devolution of power to Panchayats and bringing Government hospitals, CHCs, and PHCs under them was a progressive step. Atleast one state Kerala implemented it in letter and spirit. Linking Primary Health Care to Panchayat Raj institutions is the most logical thing to do. This enhances the ownership and the sense of belonging of the local community. NRHM was a good experiment and has had a revitalising effect on Rural Health.

The comprehensive Primary Health Care document of the current Government speaks of several dimensions; yet still falls short of Alma Ata’s declarations. The major fallacy with its conceptualisation remains the advent of a non-medical mid-level provider. This betrays the lack of political will to invest in Health. The administrative slugfest that has led to this sub-Saharan solution for our people deserves contempt. With Covid breaking such traditional barriers in the mindset of the Governments it is time to reset the clock. India has 554 medical colleges and 83075 fine MBBS graduates walk out every year. Around 40,000 foreign medical graduates take the qualifying National Board examination every year. The Government is in a proactive mode in creating more medical colleges. It can be safely assumed that around one lakh doctors graduate every year. This number is unique. Sooner than later India will have enough and more doctors to meet the needs of the entire humanity. What has to be managed is the regional disparity and the urban bias.

There has been a systematic devaluation of MBBS as a degree due to wanton neglect and biased attitude. The casual approach by the bureaucracy has led to the exploitation of MBBS graduates through ad hoc contract postings for paltry remuneration. These half-hearted attempts have created an artificial vacuum. While there are a glut of fine medical graduates the Government maintains the posturing of lack of doctors. The entire NHS of the UK is run by MBBS doctors. Most of them are from India. It is strange why the successive Governments have failed to cash on this national asset. The blame for the failures in primary care and Rural Health have been unfairly laid at the doorsteps of young doctors. We have an adequate number of doctors to staff our sub-centers. In Tamil Nadu and Kerala, the doctor population ratio is less than 1: 500. The Government should radically alter its thinking. At any given point of time around one lakh and fifty thousand MBBS graduates are unemployed and are populating the entrance coaching centres. Doctors spend 2 to 3 years to get into post-graduate courses. The Government is directly responsible for this criminal waste of medical manpower by not expanding the structure of Primary Health Care and not deploying them in suitable permanent jobs. An MBBS doctor today does not have any relevance either in the Government sector or the Private Sector. He can neither survive on his own because of “you are only an MBBS attitude” of the people.

Deployment of MBBS doctors in the proposed wellness Centres in permanent jobs or a three-year short service is a solution. The three-year short service can be part of a new All India Cadre on attractive scales. As pioneered by the erstwhile Medical Council of India this can be incentivised with dedicated marks for post-graduate education. All sub-centres should be manned by MBBS doctors. This will give meaning to these wellness centres. Paying lip service to Primary Care by forming endless committees and blaming doctors for the failure of Rural Health will no longer sell. Radical restructuring and optimum use of medical manpower can rapidly change the scenario. Inflicting non-medical care on villagers is a crime against humanity and the directive principles of the constitution. (The authors are Past National President and Secretary-General of Indian Medical Association respectively)

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