The lesson emerging most unequivocally from the pandemic experience is that if India does not want a repeat of the immeasurable suffering and the social and economic loss, we need to make public health a central focus. The virus is still around. We have no option but to live with that reality.
Covid has also shifted the policy dialogue from health budgets and medical colleges towards much-needed and badly-delayed institutional reform. It is heartening to note that the Ministry of Health has issued guidelines to states to establish a public health cadre.
The importance of public health has been known for decades with every expert committee underscoring it. Ideas ranged from instituting a central public health management cadre like the IAS, to assess, manage and control public health problems to adopting an institutionalised approach to diverse public health concerns — from healthy cities, enforcing road safety to immunising newborns, treating infectious diseases and promoting wellness.
The process of reform to create a public health-centred primary healthcare system needs to start with looking evidence in the eye. After 15 years of the National Health Mission (MHM) and a trebling of health budgets — though not as a proportion of the GDP — less than 10 per cent of the health facilities below the district level can attain the grossly minimal Indian public health standards. Clearly, the three-tier model of subcentres with paramedics, primary health centres with MBBS doctors and community health centres (CHC) with four to six specialists has failed. Why, one might ask.
The model’s weakness is the absence of an accountability framework. The facilities are designed to be passive — treating those seeking care. Instead, like in Brazil, we need Family Health Teams (FHT) accountable for the health and wellbeing of a dedicated population, say 2,000 families. The FHTs must consist of a doctor with a diploma in family medicine and a dozen trained personnel to reflect the skill base required for the 12 guaranteed services under the Ayushman Bharat scheme — midwives, public health nurses, other paramedics, health workers and community workers. A baseline survey of these families will provide information about those needing attention — the elderly, diabetics, hypertensives, handicapped, pregnant women, infants, and those needing mental or physiotherapy services. The team ensures a continuum of care by taking the family as a unit and ensuring its well-being over a period. Nudging these families to adopt lifestyle changes, following up on referrals for medical interventions and post-operative care through home visits for nursing and physiotherapy services would be their mandate. Their work should be closely monitored and the personnel should be given outcome-linked monetary and non-monetary incentives.
Such a system of primary care will need to work under the close supervision of a CHC manned by specialists in family medicine. If trained well and competently, they can handle most ailments and conditions that could and should be handled at the CHC level, referring only those needing specialist care.
The implication of and central to the success of such a reset lies in creating appropriate cadres. More immediately, there must be a public health cadre manning the posts at the PHC and CHCs consisting of sub-specialists in family medicine, public health and public health management. Likewise, among nurses, the cadre should comprise two distinct sets of personnel — public health nurses (not ANMs promoted based on seniority) and nurse midwives capable of independently doing all clinical functions for handling pregnancies and women’s health issues except surgical interventions. Primary care in India can get traction only if new skills, drastically upgraded competencies and a new mindset are embedded within the vision of a patient, family and community-centred health system.
There is also a need to declutter policy dialogue and provide clarity to the nomenclatures. Currently, public health, family medicine and public health management are used interchangeably. They should not be, just as cardiology and neurology should not be used interchangeably though both are clinical disciplines. Family medicine is the clinical arm of public health. The MBBS doctor goes through a two-year training in family medicine, specialising in disease control — communicable and non-communicable diseases, knowledge of health determinants such as nutrition, in addition to imbibing a comprehensive psycho-social understanding of the community being served and good communication capabilities. His training site is a district hospital. The public health specialist, in contrast, is a doctor or a graduate in an associated discipline, specialising in biostatistics, data sciences, epidemiology, health determinants and other population health-related issues. His training sites are dusty villages, densely populated slums, disease-prone areas and laboratories. Thus, while the family doctor cures one who is sick, the public health expert prevents one from falling sick.
The public health management specialist is a different animal — with specialisation in health economics, procurement systems, inventory control, electronic data analysis and monitoring, motivational skills and team-building capabilities, public communication and time management, besides, coordinating with the various stakeholders in the field. His training grounds are management institutions, public health departments that implement the National Health Programmes and a two-year probation where he works through the health system (like IAS officers). Such trained persons are the ones who ought to work as CMHOs (chief medical health officers). Imagine the energy and skills that such young, well-trained persons would bring to the district health administration and later as the DGHS, instead of the current arrangement where the DGHS could be a doctor who has never stepped out of the operation room in a Delhi hospital. The training of the cadre will not require medical colleges. But the competence of trainers, the way to be trained, the content and pedagogy require imagination.
Alongside, India needs to move beyond the doctor-led system and paramedicalise several functions. Instead of “wasting” gynaecologists in CHCs, when there is an overall shortage of them, midwives (nurses with a BSc degree and two years of training in midwifery) can provide equally good services except surgical, and can be positioned in all CHCs and PHCs. This will help reduce C Sections, maternal and infant mortality and out of pocket expenses. Likewise, lay counsellors for mental health, physiotherapists and public health nurses are critically required for addressing the multiple needs of primary health care at the family and community levels. This needs to be acknowledged and such trained persons appropriately positioned based on patient load and disease burden.
Bringing such a transformative health system will require a comprehensive review of the existing training institutions, standardising curricula and the qualifying criteria. Faculty reviews are required to make the training inspirational and not dull and repetitive, as it is currently. Spending on pre-service and in-service training needs to increase from the current level of about 1 per cent. And, finally, a comprehensive redefinition of functions of all personnel is required to weed out redundancies and redeploy the rewired ones.
It is time our political systems listen to peoples’ voices for a family doctor to ensure their everyday needs — and not easy options like privatisation, commodification and medicalisation of the system. Resetting the system to current day realities requires strong political leadership to go beyond the inertia of the techno-administrative status quoist structures. We can.