August 2018 STRENGTHENING PRIMARY HEALTH CARE IN RURAL INDIA REPORT AND RECOMMENDATIONS OF A NATIONAL CONSULTATION Strengthening Primary Health Care in Rural India The national consultation on strengthening primary President of India, Mr M Venkaiah Naidu, inaugurated healthcare in rural India was convened during the 15th the conference. Mr Ashwini Kumar Choubey, Minister of World Rural Health Conference, organized by the State for Health and Family Welfare, Government of India, and Mr Manoj Jhalani, Mission Director of the National Health Mission (NHM) also spoke in the inaugural function. The conference culminated with the unanimous adoption of the Delhi Declaration, calling for people living in rural and isolated parts to be given a special priority if nations are to achieve universal health coverage. (www.who.int/hrh/news/2018/delhi- declaration/en/) The National Consultation on Strengthening Primary HealthCare in Rural India was nested within the conference, hosted by Academy of Family Physicians of India, and convened by Basic Health Care Services Trust. Academy of Family Physicians of India in association Niti Aayog, National Health Systems Resource Center with WONCA Rural Health (World Organisation of (NHSRC), Public Health Foundation of India (PHFI), Family Doctors). More than a thousand experts and Knowledge Integration and Translation Initiative (KnIT), practitioners (1044) from 40 countries participated in and WONCA-Rural co-hosted the consultation. this international conference, held at India Habitat Dr Vinod Paul, Member, Niti Aayog delivered the Centre, New Delhi from 26-29th April, 2018. The theme keynote address of the consultation. A range of national of this conference was “Healing the Heart of Healthcare and international experts participated and spoke at the - Leaving No One Behind”. The Honourable Vice consultation.

Co Hosted by: I will give you a talisman. Whenever you are in doubt, or when the self becomes too much with you, apply the following test. Recall the face of the poorest and the weakest man [woman] whom you may have seen, and ask yourself, if the step you contemplate is going to be of any use to him [her]. Will he [she] gain anything by it? Will it restore him [her] to a control over his [her] own life and destiny?

-Mahatma Gandhi, 1948. Contents

Executive Summary 1-3

Background 4

Setting the Stage 5-6 1. Family Physicians and primary health care in rural India : Dr Raman Kumar 2. Policy initiatives for strengthening primary health care in rural India : Dr Rajani Ved Key Note Address: 7 India’s Path to Universal Health Care: Dr Vinod K Paul, Member, Niti Ayog Global and Indian Evidence 8-10 1. What makes primary health care work in rural areas : Global Evidence: Dr Bruce Chater 2. What makes Primary health care work: Indian evidence : Dr Rajesh Kumar Experiences from India 11-17 1. CMC Vellore equips doctors for rural health care : Dr Anand Zachariah 2. Providing comprehensive health care in rural Central India : Dr Yogesh Jain 3. Team approach to deliver health care in tribal Rajasthan : Dr Sanjana B Mohan 4. Stated Funded Health Insurance in Karnataka and its implications for primary healthcare : Dr N Devadasan 5. Experience of deploying mid-level health workers in rural Chattisgarh : Mr Samir Garg 6. NRHM experience of nominating rural physicians for Family Medicine Training : Prasanth K Subrahmanian. 7. Using technology for delivering healthcare in rural areas : Dr Sabahat Azim Global Experiences 18-22 1. Strengthening Healthcare in Rural Locations: Experience from Queensland, Australia : Dr Bruce Chater 2. Restructuring primary healthcare in South Africa : Dr Ian Couper 3. Evolution of Family Practice in Brazil and its implications for India : Dr Mayara Floss 4. Transforming a Rural hospital and building a rural training site in Nepal : Dr Bikash Gauchan 5. Global Evidence on effectiveness of Mid-level providers for Primary healthcare : Dr Chandrakant Lahariya Comments by Experts 23-26 1. Dr Rajiv Sadanadnan, Additional Chief Secretary, Government of Kerala 2. Dr Maharaj K Bhan, Ex-Secretary, Department of Biotechnology 3. Dr Paul Worley, Commissioner, Rural Health, Government of Australia 4. Dr Roger Strasser, Dean, North Ontorio School of Medicine, Canada 5. Dr Preeti Kumar, Vice-President, Public Health Foundation of India Recommendations 27-28 List of Participants and Affiliations 29-30 Executive Summary organizations that work in from four states central and state Background difficult to reach rural (Chattisgarh, Tamilnadu, governments' budgets put India has made significant areas have also worked on Karantaka and Rajasthan) together would indeed be advances in improving innovations to improve and four countries spent on primary health health of its populations for access, responsiveness and (Australia, Brazil, South care in the coming years. quality of primary Africa and Nepal) were over more than a decade, Dr Rajani Ved, Executive healthcare. Finally, there shared, and discussed reducing the gaps between Director, National Health are substantial, long-term collectively with global rural and urban areas, and Systems Resource Center, experiences of several evidence. This report between the rich and the spoke about the new countries that have provides a summary of poor. However, huge comprehensive health care addressed the problem of discussions and key disparities still remain, and system that includes the delivering universal, high recommendations access to healthcare in expansion of service quality primary health care, emerging from the rural areas continues to delivery beyond maternal to the most underserved consultation, especially pose a significant and child health, assured populations. Their those that have a relevance challenge. There is a availability of medicines cumulative experiences for India. growing recognition that and diagnostics, expansion can inform and guide India needs to build a of human resources, India's policy directions strong comprehensive emphasis on health into action. Policy Context primary healthcare system awareness, leveraging of Dr Vinod Paul, Member, to accomplish any further private sector partnerships Niti Ayog, highlighted the advancements in the and initiation of Purpose political commitment made overall health status of its performance-based A one-day national by the Prime Minister of populations, and to reduce incentives. However, there consultation was held on India, who recently any disparities. The are several challenges in 27th April, 2018 to identify launched the health care National Health Policy of achieving comprehensive those elements that could mission of India, i.e. 2016 and budgetary primary health care in guide India's efforts at Ayushman Bharat, from a announcements made in India: rising out-of-pocket improving health care in village in Chhattisgarh. 2018 (better known as the expenditure, changing rural and underserved Ayushman Bharat is a two- Ayushman Bharat scheme) epidemiology (double areas. Nested within World pillared program, which have two components of burden of diseases), Rural Health Conference aims at creating strengthening healthcare exclusion from healthcare 2018, the consultation comprehensive primary in India: a) improving due to social and access and quality of geographic primary health care marginalization, and low through the strengthening utilization of primary of 150,000 sub-centers health centers included. and PHCs (transforming There is also a huge them into health and shortage of manpower at wellness centres), and b) the primary health care improving access to level: for example, less than secondary and tertiary 40% PHCs have the care through an universal necessary two doctors (as health insurance scheme. stipulated by Indian Public With improving Health Standards infrastructure and rural guideline). access, some state It is hoped that the above governments have brought together a range health care in India, and challenges will be gradually designed and implemented addressed through the re- innovative solutions to of health care simultaneously at practitioners, policy providing financial designed Ayushman Bharat address the problems of program. access, as well as makers and academicians protection for millions of affordability of healthcare. from India and other individuals. Dr Paul Many not-for-profit countries. Experiences reaffirmed that 65% of the

1 Evidence on What Works for Rural Primary Care Family-centred Along similar lines, there functions: patients should a new cadre of Rural health care: There is are concerns in South first themselves at PHCs, Medical Assistants overwhelming evidence Africa and Brazil that and only when referred (RMAs) helped in that a public health reduced public by PHCs, should they be significantly improving approach that focuses on expenditures in primary entitled for insurance the utilization of primary family-centred care, and health care will inhibit cover under NHPS for health centers in some of comprehensive and provision of health care to secondary or tertiary the remotest areas of the continuing care, helps the most marginalized care. Such an state. A review of global improve health care of populations. arrangement would help evidence, shared by the any rural population. Such in increasing the WHO India Country State-funded health utilization of PHCs and Office, concluded that an approach integrates insurance and preventive, promotive maintain the primacy of non-physician providers, and curative care, and is implications for primary health care. It when well-trained, delivered by health primary health care: would also help in equipped with the providers (doctors, nurses There are concerns that ensuring the efficiency of necessary skills, and other health India's investments in the the NHPS, by reducing supported and professionals), who are National Health unnecessary referrals. supervised, can deliver quality health care for a trained to manage a range Protection Scheme Building and (NHPS) will promote range of conditions. of conditions, from safe empowering primary childbirths and maternal secondary and tertiary At the same time, the idea care to communicable health care, at the health care teams: that India has a shortage diseases and non- expense of primary health Most presentations on of physicians was communicable diseases. care. The consultation the day highlighted the contested. Physicians are Providers are further brought about evidence need for comprehensive unavailable to work in trained to work in teams, and experience that will health care – the ability to rural areas not because understand community be helpful in the country's prevent and treat there is a shortage: they needs, and engage with attempts at a turn around. maternal and child health are reluctant to work in them actively. these areas because of inadequate living and Higher investments working conditions, low in health care: India wages and poor training spends only a small opportunities (see next proportion of its national section). Though the role budget on health care. of non-physician or mid- Increased budgetary level providers was allocations to the considered important to National Rural Health improve access, many Mission in previous years experiences shared in the led to significantly consultation, such as that improved health from South Africa, outcomes. Most of this Rajasthan and improvement occurred in Chattisgarh, highlighted a Courtesy: Basic Healthcare Services rural areas, reducing team approach. The team health inequalities. Firstly, NHPS could conditions, as well as includes a physician (a However, overall include primary health communicable and non- family physician), and budgetary allocations to care services. There are communicable diseases non-physicians: Nurses, health care remain low, several examples: in high and injuries. Because of a other healthcare around 1% of the national income countries such as shortage of physicians in providers and community Gross Domestic Product Australia, and in low- rural areas, various health workers. Such a (GDP), restricting optimal middle income countries government- and non- team appears to be improvements. Within such as Thailand, where government critical to provide India, there is evidence state funded health organisations have comprehensive primary that states those who insurance covers primary engaged non-physician health care through spend higher proportions health care in rural areas. providers to provide improved access, quality of their budgets on health Secondly, Primary Health healthcare in rural areas. of care, culturally care have better health Centers (PHCs) should For example, in sensitive care and equity. outcomes than those who retain the gatekeeping Chhattisgarh spend lesser.

2 Training of rural education is conducted in education, research and Post-training support healthcare specialized tertiary care services to address priority and placement: settings and is geared concerns of rural Global Evidence suggests that professionals: towards providing care in communities. A socially evidence suggest that improved living and such settings only. accountable rural medical working conditions, better comprehensive health care Contrary to this precedent, school helped in addressing is effectively provided by a salaries, use of disruptive we found that in rural health needs of the technology, co-operative workforce (especially Queensland, Australia, populations of North doctors and nurses) that is arrangements with other medical education is Ontario, Canada. rural health facilities, and trained to practice geared towards a Rural training sites continued training, all help comprehensive health care. generalist approach that CMC Vellore has an doctors and nurses provide Above all, they should be includes training in and for affiliated group of about high quality care in rural mentally prepared to offer community based primary 200 secondary hospitals, areas. In CMC Vellore, a a full scope of services to medical practice, health largely in rural and remote long-distance training the rural constituency they facility based secondary areas, that act as training program on family serve. In order for them to medical practice and sites for non-medical medicine helps the be effective in their work, hospital and community personnel such as graduates enhance their their training should take based public health physicians and nurses. skills and sense of place in rural health practice. facilities, and trainees Their experiences suggest affiliation. In Nepal, the should be embedded in Social accountability that training large numbers staff of the rural hospital at rural communities. Such a mandate of medical and of doctors and nurses will Bayalpata receive training requires sufficient nursing schools require community based continued training and duration and can not be WHO defines social rural training sites, public exchanges. hurried through. accountability of medical or private, where they can Merely making it schools as the obligation to practice and learn primary Primary health care or a mandatory for nurses and direct their education, and secondary health care. doctors to work in rural generalist approach research, and service Another such example can In rural areas, the health areas does not work, in activities towards be found in the Bayalpata absence of adequate professionals need to addressing the priority hospital, in Nepal. provide care for a range of training, improvement in health concerns of the Experiences also suggest living and working conditions, to people communities they serve. In that it is an additional across the life cycle. They conditions, and career the context of rural incentive, when doctors progression. need to have a range of primary care, socially and nurses in these clinical, social and accountable medical or a facilities are accorded a leadership skills. Current nursing school would direct faculty position. medical and nursing

3 Background There are several care systems have Translating the have a limited coverage, definitions of primary better health policy directions into their experience, insights health care, but most and evidence from the outcomes, lower action: With a growing have the following key ground has substantial inequalities in these economy, India's rural elements: potential to inform future outcomes, and lower infrastructure is programs and policies. l Primary healthcare costs of care. improving, as is the access Finally, there are includes preventive, to technology. All of these Policy directions for substantial, long term promotive and have the potential to experiences from several curative care strengthening transform the health countries that have status of its populations. l Care is provided primary healthcare addressed the problem of Different state within or closer to India's National delivering universal, high in India: governments have set up the communities quality primary health Health Policy 2016, along strong primary health they serve with the budgetary care, particularly to the care systems, each of underserved populations. l Primary health care announcements made in which have their own is universal in nature, February 2018, take a unique features. Against the above but focuses on the two-pronged approach Experiences from these background, a national most marginalized for strengthening health programs can consultation on rural healthcare in India: guide further course of primary health care was l It provides person- action. Many not-for- conducted in New Delhi focused and l Improving access and profit organizations that on 27th April 2018, with population-focused quality of primary work in difficult to reach following objectives: care rather than the health care through strengthening rural areas have also 1. To share learnings disease focused care worked to innovate, in 150,000 sub-centers from experiences Because of these order to improve access, (transforming them and evidence of rural features, primary health responsiveness and to health and primary healthcare care helps in promoting quality of primary wellness centers), within India and health related behaviour, healthcare. For example, from across the and preventing ill health, and to offset the shortage of world; detecting and treating the l Improving access to physicians in rural and 2. To identify key secondary and inaccessible areas, some illnesses early, closer to elements of strong tertiary care through programs have worked where families live. Any primary health care a near universal with primary care nurses, health system needs to systems that can health insurance while others have used have a balance of primary, strengthen primary technology for improved secondary and tertiary scheme. health care in India; diagnostics and for tele- healthcare. Information and insights and consultation and training. Evidence from across from different sources, Notably, most state-run 3. To explore the world indeed both within and outside health programs have partnerships for India, have been helpful in shows that the partnered with strengthening achieving these policy countries that have communities to promote primary health care objectives. community participation. in rural India. strong primary health Though these models

For purposes of the consultation, we have defined primary healthcare system as one that provides preventive, promotive and primary curative care, is located within the communities and engages them, provides technically appropriate care by appropriately skilled providers. It has good linkages with the secondary and tertiary healthcare sector, and helps the families to navigate these levels of care when required. A standalone health post or a health worker or delivery of selective interventions is not considered primary health care in this definition.

4 The consultation brought context was provided on together a range of primary the day by representatives health care practitioners, from the Niti Aayog and policy makers and National Health Systems academicians from India Resource Center. The and other countries, who Academy of Family shared testimonies and Physicians of India, and evidence gathered from World Family Physicians the field. Experts from Association-Rural some of the leading (WONCA-Rural) provided institutes in India and the physicians' perspective overseas were in of strengthening rural attendance. India's policy primary care in India. Dr. Raman Kumar, AFPI, speaks at the inauguration of the consultation Doctors and Nurses need skills and support to provide comprehensive health care in rural areas Dr. Raman Kumar is founder Dr. Kumar emphasized the argument that there aren't private sector, doctors, and President of Academy of need for general enough doctors to provide nurses and other Family Physicians of India, practitioners or family primary health care and healthcare staff do not which co-hosted the World physicians i.e. those that argued instead that receive adequate salaries Rural Health Conference- and support. He mentioned 2018. Dr Kumar is a strong that an expected one advocate of family-centred million MBBS graduates healthcare in India. will join the Indian workforce in the next five Dr. Raman Kumar spoke of [Nurses] are able to go to war zones…they are to 10 years. It will be vital the key barriers that young able to go to Iraq. Why can't they go to Bihar, to India's health systems doctors face when they Jharkhand, Chhattisgarh? Why can't we attract that they are “engaged enter the primary health them there? We must think about this. fruitfully” to provide care system in rural India: comprehensive healthcare. high levels of morbidity, the A compulsory rural posting, changing disease burden, in absence of the requisite and inadequate skills to - Dr. Raman Kumar, training, salaries and deal with the setting. He support, is not a suitable raised the concern that President, Academy of Family Physicians of policy option. He also MBBS courses currently India. emphasized on starting train doctors to work in family medicine tertiary care settings, not departments at all medical in the setting of a rural are trained in family doctors haven't been colleges in India in primary health care centre. medicine and are skilled to equipped or offered compliance to NHP 2017 Revisiting the Mehta provide comprehensive necessary resources to and 92nd parliamentary committee report (1983 – care for people of all ages work in rural areas. standing committee on '84) and the National and requirements. Dr. According to him, in the HFW 2016 report. Health Policy (2002), Kumar also disputed the government as well as the Policy initiatives for strengthening primary health care in rural India Dr. Rajani Ved is Executive policy initiatives of comprehensive primary primary health care, whose Director, National Health Government of India, health care system, we recommendations formed Systems Resource Center. aimed at strengthening cannot hope to accomplish the basis of the new health NHSRC provides technical primary health care. major advancements in care design. Accordingly, assistance to the Ministry of Comprehensive health care health status of financial commitments Health & Family Welfare, is one of two pillars of the populations. In turn, strong were made in the 2017 India, and closely works with newly launched primary health care union budget for turning the National Health Mission. programme, Ayushman programs need strong 150,000 sub centres and She is at the forefront of the Bharat (the other being health systems in place. In PHCs into health and Government of India's plan National Health Protection an effort to address this wellness centres by 2022, to strengthen comprehensive Scheme). There is a gap, the Ministry of Health starting with about 15,000 primary healthcare. recognition now that and Family Welfare had centres in 2018-'19. unless India builds a strong set up a task force on Dr. Rajani Ved spoke on the 5 Besides the financial - Rising out of pocket down to the community severity. The policy allocations, training expenditure: People level. response has been to courses have been spend almost double develop referral - Low uptake of primary introduced in order to the amount out of their protocols and robust health care: The third bring in additional staff in own pockets on health information major challenge is the the form of Ayurveda as compared to the technology-based low uptake of care in practitioners and expenditure by the solutions, maintaining a primary health centres community health officers, government. In the rest continuum of care from across the country. The and creating a new cadre of the BRIC countries community to facility. response to this of accredited mid-level this ratio is inverse. challenge has been to - Reaching out to the most providers. The re-designed Governments spend transform the lower underserved Ayushman Bharat program much higher level health facilities populations: Finally, has also drawn proportions on health into 'health and around 20% of people considerably from the care in comparison to wellness centres', continue to exist “leveraging [of] learnings” those spent by citizens increasing investment outside the ambit of from previous attempts at out of their own in these centres and public health care due health systems pockets. The policy ensuring that they are to marginalisation, strengthening. Measures, response is to expand close to the community. including physical or such as the launching affordable services at social exclusion. The ambulance services, the rural and primary - Fragmented structure of government response strengthening level. care: Another big issue has been to carry out infrastructure and adding is the fragmented care. - Double burden of population human resources at every We have no gate- diseases: While India enumeration to level, have all contributed keeping function, “at has seen a decline in estimate exact towards building a strong any level”, with patients neo-natal deaths and denominators for each base for the proposed accessing primary, deaths due to facility. With such redesign. Moving ahead, secondary and/or respiratory diseases, knowledge, primary expansion of service tertiary care facilities the burden of deaths health centres should delivery beyond the for the slightest or the due to non- know how many people maternal and child health, biggest complaints, communicable diseases they've been set up to assured availability of thus fragmenting the has increased. The serve, and in which medicines and point of burden of care and policy response is regions or areas they care diagnostics, compromising the screening, prevention live. Citing the United expansions of human quality of care that can and management of the Kingdom example (of resources and “multi- be offered for health five common NCDs, and communities or skilling” of the existing complaints of any taking care of NCDs neighbourhoods being ones, greater emphasis on registered at particular health awareness, Figure-1: Comparison of Out of Pocket and Government health care centres), Dr. leveraging private sector Health Expenditure, India and Select Countries Ved emphasized that partnerships and initiating this future empanelling performance-based Out of Pocket Expenditure (OOPE) exercise will help sub- incentives are some of the OOPE as % of THE GHE as % of THE centre (to be health and key initiatives that will 84 83.6 83.1 78.2 wellness centre) staff define a comprehensive 77 77.8 62.4 actually “target their primary health care 56.1 55.8 52.2 services” based on the system. 45.8 46.0 48.3 42.1 population. Dr. Ved also shared an 30 32.0 25.5 It is hoped that the above 14.1 14.0 13.2 iteration of some of the 11.9 11.0 9.7 6.7 challenges will be key health care challenges gradually addressed in India, as well as y azil UK through the re-designed USA ance India China r Russia Br Japan F proposed policy responses Sweden Sri Lanka German Thailand Ayushman Bharat program. to these challenges:

6 India's path to universal health coverage Dr. Vinod K. Paul is full-time Dr. Vinod Paul highlighted Member of Niti Aayog, the the political commitment premier policy 'Think Tank' of made by the Prime the Government of India. He Minister of India, who is a renowned paediatrician recently launched the and medical researcher and primary health care has contributed significantly mission of India, i.e. to shaping India's policies Ayushman Bharat, from a and programs on maternal, remote village in new-born and child health. Chhattisgarh. This Dr. Paul leads the health and commitment comes along nutrition portfolio at the Niti with the acknowledgement Aayog. that health indeed is a “political narrative” in Dr. Vinod Paul, in attendance at the inaugural session of the consultation. India. Ayushman Bharat is a two-pillared, umbrella vector control, yoga, indoor systems. Citing the recent program, which aims at pollution etc.). Such eradication of polio in the creating comprehensive comprehensive service country and ongoing Swach We are seeing a game- primary health care in India packages can serve defined Bharat (Clean India) changer emphasis on while simultaneously catchments consistently mission as examples of health in India…with providing financial and cater to people of all public action in protection for millions of ages and backgrounds. To development, Dr. Paul resources like never individuals (also referred to that end, Dr. Paul asked asked the participants to before…our key as “Modicare”). He that the participants of the share learnings and mandate is to turn reaffirmed that 65% of the consultation contribute by contemplate the ways in development [health] central and state making suggestions which these movements governments' budgets put towards comprehensive can be emulated, to create into a people's together would indeed be care packages that can a comprehensive, inclusive movement. spent on primary health meet all of these and participatory health care in the coming years. requirements, as well as care mission. Dr. Paul also ways in which they can be emphasized that solutions Dr. Paul emphasized that delivered. be found to encourage the key to strengthening participation and inclusion In addition to this, Dr. Paul primary health care is to in defined catchment areas; emphasized the critical role make it comprehensive; by for example, Panchayats or -Dr Vinod K. Paul, of “jan bhagidari” or bringing all specialised village-level leaders can Member, Niti Aayog people's participation in interventions together, play a significant role in setting up successful combined in service encouraging inclusion and primary health care packages (for example, establishing inclusive

7 Global and Indian Evidence

8 What works for rural primary care? Global Evidence Dr. Bruce Chater is Medical The rural generalist “Those people need to Dr. Chater also explained Superintendent & General movement has been have a full scope [of that medical Practitioner in the small adopted in Canada, medical practice], if we professionals must be rural town of Theodore in Australia and other are to comprehensively integrated or embedded the state of Queensland. He western countries, and cover that scope [rural with the communities is also Secretary of Rural more recently in Japan. catchments] with the they serve, and thus and Remote Clinical The key to such a practice others in the team.” either come from those Network at Queensland, would be to not specialise communities and/or be He also underlined that Head of the Discipline of in one kind of medicine sent to school and trained the attitude and training Rural and Remote Medicine within rural communities. at University of “It is important that rural Queensland, Australia and doctors be seen as the Chair, WONCA working best of doctors, not the party on Rural Practice. worst of doctors.” There's “overwhelming In order for medical evidence” on what works professionals to live and for rural care around the work better and practice world. Dr. Bruce Chater a more general scope of drew from his learnings as medicine, they would a rural physician and an need improved living and academician to discuss financial conditions along some of his findings over with professional decades of experience support. Dr. Chater serving people in argued that in the Indian Theodore. Dr. Chater Dr. Bruce Chater addresses the participants context, the compulsory explained that generalist on global evidence on rural primary health care placement in rural doctors can do a lot to settings – a controversial deliver comprehensive but be able to manage a needed of a young and sometimes sore point and continuing care and range of conditions. graduate entering the for MBBS students in the integrate preventive and field, is that they be past –does not and should To that end, Dr. Chater promotive care in the willing to receive not absolve the system emphasized, young process. Family-centred appropriate training and from making the medical graduates who care as practiced by be mentally prepared to placement an attractive get to work in rural areas generalist doctors, takes a offer a full scope of training opportunity for should come out of population-driven health services to the rural young doctors with the medical school with both, approach, that involves constituency, with the right facilities and the ability and the delivering everything support of disruptive appropriate monetary attitude to carry out a from primary health care technology, external compensation. The wide range of procedures, to secondary and subsidies, support and bottom line, according to treatments and follow emergency care across two-way cooperative Dr. Chater, is that policy- ups. “There's no point in age groups – whatever arrangements with other makers must (be willing having someone who the population or the rural health care set ups to) invest in facilities, specialises in one catchment area that the where needed. With good housing, technology discipline, practice in rural or family doctor is these measures towards support (“not rural [settings],” meant to serve, needs. integration of services, substitutes”), and much Dr Chater explained. higher wages for postings Figure-2: Impact of investment in housing infrastructure in rural settings, in order on nurses opting for a rural job in Ethiopia to encourage a flow of human resources to rural areas. This way, Indian Discrete Choice Experiment administrators and politicians can expect to get “more bang for their buck” in rural primary Nurses in Ethiopia health care systems. Dr. Chater noted that Willingness to accept a rural job Indian evidence in medical journals have in A dose response curve the past noted the same actionable observations. 9 What has worked for primary healthcare in rural areas? A discussion of Indian evidence Dr. Rajesh Kumar is currently In 2002, the National Health Activists (ASHAs), current structure of the Dean (Academic) of the Health Policy identified nursing staff and allopathic primary health care Post Graduate Institute of weak primary health care doctors. All these inputs services and the reforms Medical Education and systems and low resources led to an improvement in brought about by NRHM Research (PGIMER), for health sector as critical key health indicators: for have served well to Chandigarh. He is a public improve access to health health physician, services and improving educationist and researcher health outcomes. and has helped Indian state Further increasing the governments reform and public investment in health strengthen their health (Dr. Kumar recommended systems. a budget of 5% of the Dr. Kumar started off with national GDP expenditure a quick recap of the history on health, 70% of which and evolution of public should be on primary health in India. Under the health care); strengthening British in India, the public the role and functionality health system originated in of PHCs and entrusting urban hospitals – there these PHCs to support the was no tier system or proposed health and population-driven wellness centers and approach. If you were sick Dr. Rajesh Kumar makes a point during his address. frontline functionaries. Dr. and there was a hospital Kumar also suggested that constraints for India's example, India's Infant near you, you could PHCs should retain the overall development Mortality Rate (IMR) fell attempt to access health role of primary indicators. It was also by more than 20 care there. Vaccination for management and referral acknowledged that though percentage points during small pox, and sanitation to secondary and tertiary public health programs this period. Increased drives were added to the health facilities covered remain the most important allocations public health programs source for delivery of to the health subsequently to address Figure-3: Per capita expenditure on preventive services, such sector were the spread of health, by state (2014-15) as immunization, private instrumental communicable diseases. sector remains the in bringing HEALTH SPENDING 2014-15 Subsequently, Health predominant source for about this Per capita spending (Rs.) Survey and Development curative care. The policy change. Committee Report (1946), recommended increased By Govt By households Total While the Himachal 2,016 2,274 4,547 popularly known as the allocations to health sector reform Uttrakhand 1,534 2,545 4,233 Bhore Committee report, and strengthen primary brought Kerala 1,208 5,033 6,801 guided the designing of health care systems. about by J & K 1,124 1,971 3,245 primary health care system Gujarat 1,040 1,626 3,060 The then newly formed NRHM led of independent India. A Tamil Nadu 1,026 2,724 4,101 National Rural Health to network of primary health Telangana 1,019 2,834 4,565 Mission NHRM helped in improvemen centers and sub-centers Karnataka 939 2,282 4,374 translating these policy ts in health Haryana were set up across India. 927 2,376 3,799 intents into action. During outcomes, Rajasthan 904 1,740 2,943 Public health programs this time, India also its full Punjab 889 4,138 5,220 took the population-based witnessed a considerable potential Chhattisgarh 880 1,838 3,151 approach and focussed on raise in health allocations was Maharashtra 763 2,684 4,502 treating and controlling Odisha 735 2,518 3,421 in national budgets. The restricted by communicable diseases MP 640 1,808 2,511 evidence suggests that low and promoting family Assam 602 1,293 2,049 with the introduction of allocations planning. Following the UP 581 2,396 3,060 NRHM, mere rhetoric on to health by Andhra 2,901 3,720 Alma Ata declaration in 573 strengthening primary certain Jharkhand 480 1,436 3,004 1978, there was a health care started states, and Bihar 338 1,685 2,047 significant emphasis on manifesting on the ground. inadequate disease prevention, health Between 2005 and 2016, improvemen promotion and community under the National Health India witnessed a gradual ts in infrastructure and participation. There was Protection Scheme. Such a expansion of human deployment of human also a focus on gatekeeping function resource deployment in resources. There was also modification of individual would help strengthen public health, with a inadequate emphasis on behaviours and social primary health care, while growing number of health promotion. environments that ensuring appropriate Auxiliary Nurse Midwives Nevertheless, Dr. Kumar communities live in. referrals to secondary and (ANMs), Accredited Social emphasized that the tertiary care. 10 Experiences from India

11 CMC Vellore on equipping doctors for rural health care Dr. Anand Zachariah is Secondary hospital needs among b. Provide adjunct Professor of Medicine at postings: Students are students faculty status for Christian Medical College, sent in small groups to teachers outside Based on CMC Vellore's Vellore, with a strong select mission hospitals in medical colleges, as an experiences, Dr. service and rural healthcare rural and remote parts of incentive Zachariah suggested that orientation. Dr. Zachariah the country for five weeks medical colleges need to c. Engage medical has been at the center of across their training be linked with the district college teachers in CMC's various efforts to period. They learn the health system and be primary and prepare medical students principles of primary and secondary care to for working in remote and orient them in the rural areas. rural realities of Dr Anand Zachariah clinical practice shared that over a period d. Provide practical of 25 years, CMC Vellore learning through the has developed several strengthening of innovations in education internships that reflect its philosophy and mission of training He suggested that a competent and distance education committed health diploma in family professionals, who can medicine, and an on-site work at the primary and mentoring support should secondary levels. Some of be offered to all medical these innovations include: graduates undergoing rural postings. The Clinical training-clerkships secondary care, as well as responsible for health diploma should be and internship training: about the role of a rural care of a (larger) convertible to an MD in Students and interns are hospital in a remote population. Dr. Zachariah Family Medicine with an posted in block hospitals location. also suggested following additional training. as members of the clinical measures to reorient the Finally, he emphasized team(s) in Medicine, Distance education course MBBS curriculum that governments should Surgery, Obstetrics and in family medicine: All towards rural healthcare. encourage different Paediatrics. The postings CMC medical graduates This would include such medical colleges to prepare them to function undergo a two-year measures as: experiment with different independently, and with service obligation period models of socially limited resources. During at rural mission hospitals. a. Provide adequate relevant medical their internship they also CMC has designed a clinical exposure to education. function as independent distance education medical students on primary care doctors. course in family medicine primary and for this period, to help secondary care Community health students as they continue training: Students are to learn while working, immersed in rural and translate their communities during the learning into practice. first three years. They live in rural communities, Key ingredients of a CMC “adopt” families, training for rural understand their socio- physicians are: economic background, 1. High quality clinical study a local health training problem and design health programmes. 2. Preparing students for independent care at Family medicine the primary- and orientation: Students secondary-level receive training in the principles of family- 3. Inculcating an centred care. appreciation of local/rural health

12 Providing comprehensive health care in rural Central India Dr. Yogesh Jain is co-founder disease-based peer of Jan Swastha Sahyog (JSS), support groups, provide a not-for-profit organization MCH and reproductive working in Chhattisgarh that healthcare, detect and looks to provide manage epidemics and comprehensive primary provide end of life care. health care to rural, tribal These centres also populations of the state. function as training centres Dr. Jain is a paediatrician for doctors and health and a public health workers. physician. The presentation Dr. Yogesh Jain shared the highlighted the importance experiences of his Tribal women in Chattisgarh using a mobile for disease surveillance of comprehensiveness, organisation, Jan Swasthya continuity of care, a team Comprehensiveness of availability as well as high Sahyog, which runs a approach that includes health care is provided by: quality of services. Such a comprehensive health care physicians, mid-level ensuring management of system is not independent program in the rural, providers and village communicable diseases, of doctors but is not overly predominantly tribal parts volunteers, and strong non-communicable dependent on doctors of Chhattisgarh that linkages between the three diseases and injuries; and either. Technology is used includes a total population tiers of care, especially in ensuring continuity of care judiciously in order to numbering 39,565 people view of changing across the three tiers of capture patient records, (62% adivasis), across 72 epidemiology of disease care. A team of health for disease surveillance villages. The program has a burden. Going ahead, mid- workers across the three and for training. three-tier approach: health level providers at HWCs tiers: village health workers at village level Dr. Jain emphasized the will need intensive training, workers at the village level, (that provide 53% of health role of HWCs; in their legitimacy and support of senior health workers and care), sub-centers settings, these centres referral facilities for ANMs at the sub-centers (equivalent to HWCs) that provide screening and fulfilling their role. (or HWCs); family doctors, provide 36% of health ongoing care for NCDs, specialized doctors, nurses care; and a referral treat common and laboratory technicians hospital, that provides 11% emergencies, manage at hospital level ensure of all health care.

Team approach to deliver primary health care in tribal Rajasthan Dr. Sanjana B Mohan is a (such as tuberculosis and The clinic team provides sessions are extremely paediatrician, epidemiologist malaria), and malnutrition, out-patient care for all age critical for behaviour and a public health public systems are far and groups, conducts safe change: for example, when physician. She is co-founder often of poor quality. deliveries, and manages the clinics started, of Basic Health Care Services and refers emergencies for pregnant women were In such areas, each AMRIT (BHS), an Udaipur based critically ill patients. The reluctant to come for ANC Clinic provides primary organisation that provides clinic is equipped to sessions even closer home, healthcare through a team low cost, high quality conduct essential tests and now they walk several of three primary care primary health care in dispense a range of kilometres to seek the care nurses, supported by a remote and rural areas of required drugs. An from clinics. Finally, the Primary Care Physician South Rajasthan through a ambulance helps in clinic staff also visit who visits the clinics once network of AMRIT Clinics. facilitating referrals to the households to provide a week, and is available designated [referral] postnatal care to mothers- Dr. Mohan described the over phone 24X7. Two hospitals. The clinic staff new-borns and especially areas where BHS operates community health workers also conduct regular vulnerable group of as remote, with limited provide linkage of the outreach sessions to patients such as those connectivity and with communities with the provide antenatal care to suffering from tuberculosis scattered, predominantly clinics. Each clinic serves pregnant women, weigh and from severe acute tribal populations living in a population of 12,000 to children under-three and malnutrition. extreme deprivation. 15,000, 95% of which is counsel their families on While there is a high tribal. behaviour change. These burden of morbidities 13 There has been a important to the progressive increase in [success] of the footfall at the clinics over initiative”, as Dr. the years, with women Mohan explained representing 62% of all to the patients. Of all the patient participants. visits, larger proportions Dr. Mohan further (60%) are managed by emphasized that nurses (with telephonic the AMRIT support from physicians, experience when required), and 40% suggests that a are managed by the team consisting of visiting physicians, with primary care support from the nurses. nurses, supported Continued availability of by physician and nurses help in ensuring community health that acute conditions are workers, can managed by the clinic on adequately all days and all times: provide comprehensive intensive training, of course, the availability about 70% of all cases of and responsive health standardization of of required diagnostic diarrhoea, pneumonia care services in remote protocols, tele- tools and drugs. and malaria are managed and rural populations. connectivity between the by nurses. Visiting However, this requires clinics and physicians and doctors provide initial detection and Figure 4: Numbers of women with RH conditions managed at AMRIT Clinic, management for a large by type of providers ( Docters or Nurses proportion of chronic diseases (60% of all visits), with continued Antenatal care Delivery care for these conditions provided by the nurses (40% of all visits). 810 Doctor 62 Doctor Regular availability of Nurse Nurse nurses, and the fact that 5223 361 they are women drawn from local communities, help in building a rapport with the communities. Contraception PID/RTI This, in turn, allows health care workers to provide 167 quality, timely responsive Doctor 429 Doctor care, especially to 877 women. “The rapport 667 Nurse Nurse that they build with the community is very

14 Stated funded health insurance in Karnataka and its implications for primary healthcare Dr. Devadasan is a public requested for the patient. on, and significantly lower Protection Scheme) can health physician with a long The hospital in turn raises a mortality (BMJ increase access of the experience of delivering rural pre-fixed bill for SAST to 2014;349:g5114). poorer families to health care and designing reimburse on the patient's secondary and tertiary Dr. Devadasan highlighted and evaluating insurance behalf. This scheme was care, without further the following factors that schemes for the poor. He is first started by the impoverishing or indebting led to success of this Director of Institute of Public Karnataka government for them. However, in such an scheme in reducing OOP Health, a not- for-profit below poverty line (BPL) arrangement, the patients expenditure as well as public health research and families, then slowly should be referred only health outcomes: training organization in extended to APL families, through a PHC- it would accrediting the providers, Bengaluru. then government reduce unnecessary pre-authorisation of employees and their referrals and promote Dr. Devadasan described treatment or surgery (a dependents. utilization and credibility the model of State Health form of gatekeeping), of PHCs. Insurance in Karnataka and He shared evidence from a adherence to rational shared evidence of its study that looked at a treatment, financial Similar principles of impact on reduction of out- population of 60,000 incentives to improve strategic purchasing can be of-pocket expenditure and BPL households, half of quality of care and pro- used by governments for health outcomes among which had access to the active [regular] contact purchasing primary health the poorer families. He scheme and the other half with patients. care services. Limited then drew on this did not. Although the qualified private providers Moving ahead, a state experience, as well as that socio-economic will however restrict the funded health insurance of other countries, to characteristics were the potential in rural areas as (such as a National Health suggest how strategic same across the two compared to urban areas. purchasing of healthcare groups, can strengthen primary those Figure-5: Patient flow, claims and reimbursement under SAST healthcare. enrolled in the scheme Through a referral system had set up with the help of the significantly Suvarna Arogya Suraksha reduced out Trust (SAST), doctors can of pocket refer patients who need (OOP) emergency care or expenditure surgeries for such illnesses (about Rs. as cardio-vascular 50,000 conditions, cancers etc. lesser), The hospital, based on the improved patient's financial viability, quality of raises a request to SAST, care, lower which pre-authorizes the hospitalizati- treatment or surgery Experience of deploying mid-level health workers in rural Chhattisgarh Samir Garg is Program Mr. Garg's presentation of human resources in PHC. Till date, 1335 Officer with the State Health described the experience health, particularly participants have Systems Resource Center and learnings from the qualified doctors. Given graduated under this act, (SHSRC) of Chhattisgarh. establishment of a Rural this shortage, the state and 1228 are employed by The Chhattisgarh SHSRC has Medical Assistants (RMAs) initiated a three- year the state in rural PHCs, as been closely involved in cadre that has come to be Diploma in Practice of Rural Medical Assistants- training and deploying Rural the “mainstay of the Health Modern Medicine and RMAs (now called Medical Assistants to and Wellness Centre Holistic Health, under a Assistant Medical improve access of remote initiative in Chhattisgarh”. new state act. The Officers). While half of and rural communities to participants of the diploma them are on regular At the time of its primary health care over the were trained in six rural positions, the other half formation, the state had to last ten years. institutes, followed by one are contractual. deal with a huge shortage year of training at a rural 15 They are trained and 2010 assessed induction of RMAs, the being inducted as Mid- expected to provide basic competence and utilization of rural PHCs level providers for Health maternal and child health prescription practices of has increased more than & Wellness Centers in care, conduct safe RMAs and compared two-fold, given that all Chhattisgarh because deliveries, suture small these to those of these PHCs have at-least they are well trained and wounds, drain abscess, paramedical personnel, one RMA, and some have are acceptable to the dress burns and apply AYUSH medical officers two. community. splints for simple and allopathic medical The study recommended [Subsequently, however, the fractures. Besides, these officers. The study that with the right state had to freeze the workers provide further looked at the training, exposure and training of RMAs after the preventive health care utilization of services and placement, clinical care Indian Medical Association and primary curative care patient satisfaction providers with shorter filed a case in the state High for other conditions. across these providers. trainings can significantly Court, questioning the RMAs performed as well A Public Health improve people's access legality of non-physicians as allopathic medical Foundation of India to primary health care in providing clinical care. At officers, and better than (PHFI) study run with the remote and rural areas. the time of publication, this other cadres. Since the NHSRC and SHRC in These RMAs are now case was still sub-judice.] National Rural Health Mission's (NRHM) experience of nominating rural physicians for family medicine training

Mr. Prasanth K l The government Subrahmanian is a Senior should invest in e- Consultant at National learning platforms Health Systems Resource for rural doctors Center (NHSRC), New In addition, it was Delhi, a technical resource recommended that state agency to Ministry of governments should set Health and Family Welfare, up Family Medicine Government of India. He Programs in medical has been involved in colleges and make rural promoting family medicine postings mandatory for training among government such programs. They rural physicians. should also develop a The National Health cadre for rural physicians Mr. Subrahmanian of the NHSRC speaks at the consultation Systems Resource Centre with clear career paths. (NHSRC) had doctors placed in rural consultants. Medical Council of India recommended areas trained in family should revise the At a national consultation particularly that rural medicine. undergraduate physicians are enrolled in on family medicine in curriculums to align more the Post Graduate PGDFM were offered 2013, the program was with rural priorities and Diploma in Family accordingly in Bihar, reviewed and following develop standards for Medicine (PGDFM) Chhattisgarh, recommendations were training sites for family offered by CMC Vellore. Uttarakhand, and in Tamil made to strengthen skills medicine. Similarly, it was NHSRC assisted in Nadu between 2010 and of rural doctors: recommended that 2018. Barring Tamil Nadu revising the curriculum l Central government Nursing Council of India (934 doctors nominated), for the course, identifying should promote develop a program for and Bihar (109 doctors the training sites, Family Medicine family centred care for nominated), there were advocating with state Programs and Nurses, who would be very few nominations governments for develop district team members at from other pilot states. appropriate posting after hospitals as training Community Health The feedback generated training, and collecting sites Centers. feedback from the trained from the candidates l [Subsequently, a few doctors. Mr. suggested that they felt Those who have medical colleges have set Subrahmanian shared there was not enough of undergone a training up an MD Program in in particular the National an incentive for them and in Family Medicine Family Medicine. Besides Rural Health Mission that there were no programs should be that, to the best of our (NRHM)'s experience of sanctioned positions at preferentially posted knowledge, other encouraging state Community Health at Community Health recommendations have not governments to get their Center for family Centers. medicine qualified been met.]

16 Using technology for delivering healthcare in rural areas Dr. Sabahat Azeem is and diagnose them, CEO of Glocal following which the Healthcare Systems same dispensary (GHS), a private would dispense healthcare organization medication that uses information prescribed by the technology to deliver consulting doctor. All health care. He is a of these interactions champion of use of would be digitally technology for health powered, and backed care. by a Clinical Decision Support System, thus Dr. Azeem shared his potentially reducing experience of the chances of developing and “human error”. setting up an IT-based integrated solution Dr. Azeem argued for health that typically, when consultation in the people think rural, form of “Digital they imagine sub- Dispensaries”. Identifying mechanism through which patients virtually, over standard facilities and access and the lack of doctors can consult with defined periods of time, service; on the contrary, qualified professionals because the setting is rural diagnosing and treating and logistical expenses those in need of primary higher, the technology, health care, Dr. Azeem facilities and services talked of the digital provided there should be dispensary providing of higher and longer- 'Hospital in a Box' style lasting quality. Dr. Azeem solution. At present suggested that solutions operational in a few like digital dispensaries are hospitals in West Bengal, crucial to bridging the Bihar, U.P. and Odisha, Dr. human resource gap in Azeem suggested that rural India, with quality and PHCs could also host the with reduction of out of digital dispensary, a pocket expenditure. Courtesy Glocal Healthcare Systems

17 Global Experiences

18 Organizing health care in rural and remote areas: Experience from Queensland, Australia Dr. Bruce Chater is Medical pathway to rural program and during public sector. The Superintendent & General generalist practice. Rural service (see inlay). students training here are Practitioner in the small generalist was defined as being motivated to rural town of Theodore in a medical practitioner Currently, in Queensland, champion the rural public the state of Queensland. He who is credentialed to the rural medical training health system, while is also Chair of Rural and service in following includes the rural sourcing support of Remote Clinical Network at settings: Hospital and generalist education technology, as well as Queensland, Head of the community based program that offers a other assistants and team Discipline of Rural and primary medical practice, two-level, online or members. Remote Medicine at hospital based secondary flexible delivery system, University of Queensland, medical practice (general training practitioners for Dr. Chater outlined Australia and Secretary, as well as specialization in clinical and non-clinical following factors as WONCA working party on one discipline), and abilities. The clinical responsible for success in Rural Practice. (possibly) hospital and streams offered include ensuring a significant community based public for seven streams: increase in doctors opting Dr. Chater shared the health practice. medical imaging, nutrition to train and work in rural journey of strengthening and dietetics, Queensland: health care in rural and A range of measures were occupational therapy, l remote areas of taken starting from pharmacy, physiotherapy, Starting early, during Queensland. internship, where a rural podiatry and speech internship A review in 2005 showed career was “marketed and pathology. l Having a champion that while there were promoted” to young The University of within the health some existing facilities medical graduates. Young system and medical practitioners graduates entering this Queensland, where this in rural areas, and there field are then given the training is offered, has l Embracing generalist was an existing college of “royal carpet treatment”. seen a progressively practice (as opposed rural and remote Their skills are advanced increased intake of to specialism) interns in rural health: medicine and a training in a range of disciplines: in l Embracing curriculum (there were emergency, mental from 10 in 2010 to 130 in 2016, more than half of appropriate also some rural medical health, MCH, and other technology schools), rural health care issues that affect persons the current participants was losing its glamour in a rural community on a are women. Most of them l Rural immersion against the tide of daily basis. The skill have chosen to work in specialization. The advancement continues rural areas subsequently: facilities were ageing. In beyond the residency from five in 2008 to 133 absence of fresh in 2016, most in the infusion of young Figure-6: Pathway to attract, train and retain rural generalist physicians in Queensland doctors, and nurses; the health workforce was also ageing. There were increasing restrictions on what GPs could or could not do. In a landmark workshop conducted in the year 2005, the famous Roma agreement was drafted. The twin goals were: supplying rural & remote Queensland with sufficient and superbly trained rural, generalist practitioners; and providing Australian (medical) graduates a premier

19 Restructuring primary healthcare in rural South Africa Dr. Ian Couper is Professor of past”. and support the rehabilitative services to Public Health at Ukwanda Community Health Clinic the covered population. PHC re-engineering is an Centre for Rural Health at and cluster of PHC Clinics attempt to revitalize SA's Dr. Couper highlighted the University of for delivering primary healthcare with the some unresolved issues in Witwatersrand in health care. Each PHC purpose of squarely this reengineered model: Johannesburg, South Africa. Clinic houses 2-3 PHC the role of Primary Dr. Couper is a care doctor is not champion of primary well defined, healthcare and team rehabilitative approach to primary services are healthcare. neglected, and the The vision for primary focus still remains healthcare in South largely MCH and Africa was shaped by comprehensiveness the National Health is difficult to achieve. Services Commission Within the UHC (1942), which was approach, there are tasked with advising not enough funds for on the establishment rural care and enough of a National Health provisions for Service (NHS), and the attracting health care Gluckman Report workers to serve the (1944), which poor, especially in envisaged a rural areas. “Where countrywide national Dr. Ian Couper responds in an exchange on global evidence does the money come health service that is from? Who will made available to all on the addressing inequity. It has outreach teams. Each PHC provide the care?” In basis of their needs, rather three key objectives: to team is staffed by one absence of these, he raised than their means. At the strengthen the district professional Nurse (team his scepticism and said time, given the political health system, to place leader), and an enrolled there is a fundamental scenario and apartheid in greater emphasis on Nurse, and six Community access flaw in the universal South Africa, this vision population-based health Health Workers (CHWs). health coverage plan and could not be implemented approach, and to pay as envisaged. However, greater attention to Figure-7: Organization of PHC Outreach Team in Rural South Africa these principles were factors outside health brought back into the sector that impact health Community national discussion post outcomes. To achieve WARD BASED PHC OUTREACH TEAM 1990 (in 2014), to help these three objectives, PHC Team responsible for providing: Primary Health Care to 1620 shape the National Health there are three key Families/households; Community Outreach Services; preventative Insurance scheme– a approaches: establishing promotive, curative and rehabilitative services mission to shape universal district based clinical health coverage for all, specialist teams with Professional Nurse with primary care being re- focus on MCH, (Team Leader) CHW 270 CHW 270 engineered to make it establishing ward based Health Promoter Families Families affordable. PHC outreach teams, and Environmental Health strengthening school Practitioner Dr. Couper emphasized the health services. role that the population- CHW 270 CHW 270 Families Families based health approach District specialist clinical CHW 270 CHW 270 plays in designing teams are composed of a Families Families successful rural health Family Physician-and a programs. He explained Primary Health Care that Primary Healthcare Nurse, an Obstetrician- re-engineering is one of and an advanced Nurse Each PHC team is raised the concern that the key elements of Midwife; and a responsible for about more and better Universal Health Coverage Paediatrician – and a 1,630 families of a ward healthcare to the poor may plan of South Africa, Paediatric Nurse. The and the families are be denied. A relevant initiated about four years District specialist team divided among six CHWs. concern for India indeed, ago. In some ways, the re- provides MCH care at The outreach team is as it launches the engineering is an attempt district hospital (secondary supposed to provide ambitious Ayushman Bharat to “recapture the care) as well as supervise preventive, curative and scheme. 20 Transforming a rural hospital and building a rural training site in Nepal Dr. Bikash Gauchan is a of serving 75,000 facilities and network of free of cost, and high- physician from Nepal, patients per year. landscaped terraces and level management and trained in general practice bio-swales designed to development trainings Set on a hilltop and emergency care and for their health care heads the continuing workers. medical education of rural There is a need for such physicians. He works with Bayalpata-like high Possible Health, a not-for- quality rural hospital profit organization that aimed at training doctors, runs a network of health nurses and other health care facilities across rural care professionals in Nepal. delivering rural health Dr. Gauchan's care. This experience also presentation looked at suggests the potential of the challenges of building public-private and expanding a rural Bayalapata Hospital in rural Nepal also acts as training site partnership in setting up hospital at Bayalpata in such rural hospitals and Nepal. When the first surrounded by terraced manage monsoon storm training sites. district hospital was slopes of the Seti River water erosion and treat (A point to note: The taken over as a public- valley, the two-hectare grey water. The private partner in this private partnership, there master plan includes 14 Bayalpata regional public-private-partnership wasn't a single health single family staff houses, hospital is working to has a substantial worker to offer medical an 8-unit dorm, new provide services for experience of managing help to the rural outpatient, emergency, communicable and non- rural health care facilities population in Bayalpata, lab, pharmacy, communicable diseases, and is driven by a vision of in Achham district. The administration, and as well as working providing high quality hospital will become inpatient buildings, new simultaneously towards health care to marginalized Nepal's first rural water supply and storage, quality improvement, populations.) teaching hospital, capable waste water treatment while providing services Evolution of family practice in Brazil and its implications for India Dr. Mayara Floss is a help build a rapport with Brazil, impoverishing the family medicine needs to Brazilian family doctor, who the communities she communities she serves be recognised in India as is a passionate advocate of serves, and promoting and making it more well and urged the family medicine and of good practices such as difficult for her to perform audience to recognise the health care of the meditation in the time she her duties. In Brazil, 150 discipline as distinct from marginalized populations. spends with them. She health teams in Rio de specialist care and She is founder of rural café, noted that these are a platform for networking particularly important for and continued education of the patients from rural physicians. marginalized families and communities. In her When the Brazilian public experience, family health system were being physicians can influence reformed, services for the access and acceptance primary care were of primary health care. designed to be highly But the other major subsidized. Family determinant in Brazil is practice was designed to Dr. Gauchan and Dr. Floss interact with respondents from the consultation] “the zip code” (i.e. where counter the you live), which is a proxy Janeiro, where she comes provide recognition in the commoditization of indicator of influence, from, are without doctors form of training at the health, with the firm belief education and resources, after the government's MBBS level to create that health is a human which can determine decommissioning them, family physicians. Dr. right. Dr. Floss spoke of whether a patient in need and their patients, though Floss also urged us to her own experiences as a gets primary care or not. needing primary care, are think about ways in which family doctor, promoting essentially back in the family physicians are not wellness and awareness In recent years, Dr. Floss long lines of the lost to private practice through home visits to her told the audience, primary emergency queues. and the commoditization patients, organising care subsidies have been of health. community activities to slashed significantly in Dr. Floss emphasized that

21 Global evidence on effectiveness of mid-level providers for primary health care

Dr. Chandrakant Lahariya is promotive care. Such income countries were not are. However, there is the National Professional MHWs include nurses, from primary care settings. evidence that they are as Officer-Universal Health mid-wives, and non- effective as physicians in Based on available Coverage, with the World physician clinicians, such as selective interventions at evidence, a WHO report Health Organisation, India medical or surgical primary care level, such as stated that “evidence, Country Office. WHO works technicians. for providing medical although limited, shows for strengthening health abortion, insertion of an A systematic review that, where mid-level systems at the country level, Inter Uterine Device, for commissioned by the providers are adequately and advocates for providing antenatal ensuring availability of care, and for detection adequately skilled and management of human resources for cardiovascular risk health. factors. Dr. Lahariya placed In summary, the context of his Dr. Lahariya argued presentation on the that to ensure implementation of Universal Health Universal Health Coverage, there will Coverage plan in India, need to expand the and the importance of role of mid-level access and availability workers, who are well- of adequate human embedded in the resources for its system, receive good achievement. One of training, support, the key strategies for recognition and pay. ensuring adequate They will also need human resources for much greater health is deployment supervision and Global Health Workforce trained, supported and of mid-level providers. regulation. Alliance, a few years ago, supervised, they can He used the following concluded that there is no deliver essential health (In balance, from this definition of a mid-level difference between the services with similar evidence, as well as health workers (MHWs): effectiveness of care quality standards as experience from Rajasthan “Mid-level health workers provided by mid-level physicians, and often for a and Chattisgarh, and from are those who have health workers in the areas fraction of the cost” (WHO, South Africa, it appears that received shorter training of maternal and child 2010). Important words a team comprising of a than physicians, between health, and communicable here are adequately Family/ Generalist physician, two to four years, but will and non-communicable trained, supported and non-physicians (nurses or perform some of the same diseases, than that supervised. other mid-level providers) tasks as physicians”. These provided by higher level and community health As stated above there is tasks include diagnosing health workers”. However, workers is best suited to limited evidence for the and treating of illnesses or there were very few provide good quality primary role of mid-level providers impairments, but not studies from low- to health care in remote and in delivering surgical procedures, and middle-income countries, rural areas.) comprehensive primary providing preventive and and even those from high-

22 y Experts Comments b

23 Dr. Rajeev emphasized that a very Dr. Maharaj K. Currently, the model of strong focus needs to be care is seen as being Sadanandan on capacity building of Bhan unresponsive, particularly by patients. Dr. Rajeev Sadanandan is a health professionals in Dr. M.K. Bhan is one of medical doctor, a policy- India urgently. India's leading biomedical Mentioning a recent maker and a bureaucrat. scientists, He has been active in academician and a health sector reforms of technocrat in the state of Kerala. He is India. He has currently serving as the been Additional Chief instrumental Secretary, Kerala. in developing Dr. Sadanandan, an reflecting on indigenous presentations made by rotavirus vaccine. He speakers from different is currently countries said that helping set up a Health experience observing a primary healthcare System Design Center that small American hospital, appears to be a salient He proposed that the aims to bridge the gaps he spoke of how nurse- characteristic of health primary health care between evidence and practitioners can be systems of more teams dedicated to health policy in India. skilled to provide high advanced countries. covering particular quality healthcare, as In a nutshell, Dr. Bhan Besides increased geographical areas, part of a multi- asked the participants to [financial] investments, should have family disciplinary team. The look at the primary health these countries have physicians backed up by positioning that a mid- care system as essentially level practitioner can invested a lot into specialists, who can talk being at the base of a capacity building of to each other through strong overall health care health professionals. established referral system: “Primary health systems. For primary care is essentially the healthcare to be driven first three floors of a Primary health care is by generalists, there must hundred floor tall essentially the first also be strict adherence building”. At the root of three floors of a Capacity building of to protocols, which many this is the concept that hundred floor tall young [medical & doctors in the Indian primary healthcare system struggle to do. prevents illnesses, that it building. nursing] graduates Another key component helps people lead happy, must be combined with to support training is to successful and productive the right attitude, affect a curriculum lives. Such a system is change that reflects the essential for rural as well -Dr MK Bhan through on the ground as urban areas. needs of the populations, training, so that they Information on the as well use information- different choices work in isolation is, can serve rural technology. (primary, secondary and according to Dr. Bhan, “a communities. Young In addition to tertiary) available in bad concept”. The people serving systems strengthening healthcare healthcare is going to be positioning instead systems, public health crucial for how people should be that mid-level in rural healthcare practitioners are part of a must talk to those value primary healthcare. healthcare team. must be promoted as establishing water, Approaching the champions sanitation and rural or discussion at hand from a He also highlighted the urban development as scientific point of view, need for creating a well, in order to ensure Dr. Bhan spoke of the medical education preventative and need to diagnose the system that strengthens -Dr. Sadanandan effective healthcare disease in people well in those who work on the systems. Citing Brazil as advance, at an early periphery, in primary healthcare. “When you an example, Dr. stage, which India's Fresh graduates from model of care is not create a system that can Sadanandan urged that medical schools in India currently equipped to do- prepare people on the are often unprepared to public health systems can for this purpose, peripheries you can provide medical care in be developed quickly if it generalists who are part actually strengthen rural areas. He has the support of the of teams at primary and public health and primary other systems. tertiary care, are likely to healthcare systems” he be much better equipped. asserted. 24 Dr Paul Worley These factors affect the Dr. Roger Rural generalists are status and funding of [evidenced to be] Emeritus Professor Paul primary healthcare, Strasser “extremely generous” – Worley is Australia's which in turn, has huge Dr. Strasser has spent they provide a wide variety first National Rural years helping to build Health and lead socially Commissioner. He accountable rural has been a education programs determined, effective and medical schools in and passionate Australia, and later in Canada. He was advocate for invited to set up the strengthening rural first rural medical health outcomes school in North across Australia. Ontario, where he currently serves as Dr. Worley suggested the of services, and as a result implications for health Dean. reasons why healthcare and well-being of carry a higher professional in rural areas remain populations, especially In response to a statement responsibility in inadequate throughout those in rural areas. that India will have comparison to specialists. the world: adequate numbers of Dr. Strasser shared his The primary healthcare doctors in next five years, experience of setting up l 50% of rural sector in Australia today Dr. Strasser reiterated that and leading the socially populations we look to is primarily private, but comprehensive primary accountable medical serve with rural this is the case because it healthcare can become school in Northern Ontario primary healthcare is irretrievably linked to “the best, and most (which has implications for efficient form of has all of its primary publicly funded health India). He shared that the healthcare, in terms of general principle there was care systems designed insurance. Dr. Worley health outcomes when the by the other 50% (by emphasized that you to build an education- health workforce is training pathway to people in urban areas), cannot have private adequately trained, skilled produce rural GPs. The and enterprise in healthcare and supported”. He then school focussed on without public contested the popular l Despite the science recruiting undergraduate monitoring and support. discourse on shortage of students from the rural and evidence to Dr. Worley also doctors as the key problem support the need for communities and provide emphasized that private for a health system, he said them learning in the rural wellness and primary care schools do that it is far more clinical setting. Following preventive, pre- not run into financial important for the system the graduation, they are emptive self-care and deficit. In the end, Dr. to ensure that the existing provided with skills knowledge, people Worley argued, it is key health workforce is required to be rural and governments alike adequately trained, general practitioners. that societies start equipped and supported. ignore these. thinking about primary “About 92% of our health care, and for the Dr. Strasser further students have grown up in common man to think emphasized that primary rural northern Ontario,” healthcare needs well about “where they think Dr. Strasser asserted, while trained family the remaining 8% come about it's going to cost practitioners and rural me money?” from other rural parts of What are the healthcare workers, who Canada. Of these, 62% of are rural “generalists”. implications to me for With this, Dr Worley rural graduates chose explained that in future, general practice in rural not taking up primary humans may be able to settings, double that of healthcare? Virtually access their genome, and national average for that medical The problem, pretty Canada. About 33% of the none! I can eat what I graduates are pursuing a professionals and much everywhere in combination of specialist want. In some societies, primary care the world, is that and general practices, i.e. people have built professionals in medical [and nursing] practices such as general particular can be trained education often trains surgeon. This way, in order implications for to understand individual to be sub-specialists even, smoking, by imposing genetics. Individual the students to become the graduates receive specialists as opposed taxes, and that has medical conditions can be intense training in family predicted and worked to generalists, and and rural practice. About been really effective. upon as a part of primary therefore does not 94% of the graduates care, which Dr. Worley equip the practitioners continue to serve northern deemed to be very Ontario as a whole, with exciting for the field of to meet the needs of 33% serving rural primary health care at rural populations. communities. The -Dr. Worley university continues to this point. offer professional development support while serving in rural -Dr. Strasser areas. 25 Dr. Preeti Kumar economic realities, Wellness Centers primary health (HWCs) and PHCs with Dr. Preeti Kumar is a care services, secondary and tertiary medical doctor, a trained located within the health services. ophthalmologist and a communities and public health practitioner actively engaging and academician. She with them are works as a national faculty important to in Public Health provide responsive “[Unless] you have Foundation of India, and services. communities as co- also serves as its Vice- service-providers' ability “Successful models come President. to engage with the from places where producers of health, communities, availability community engagement Dr. Preeti Kumar unless we see them as of skilled and multi- is high, and the emphasized repeatedly people first, this model disciplinary team and its community is where we about the value of integration with must start to revamp of [rural] primary community engagement. secondary or tertiary India's primary and rural In response to a question healthcare may not be health services, would be healthcare systems”, on key attributes of successful. key in ensuring quality Dr. Kumar said. She also primary health care primary care response. spoke on the need for services that affect its having a strong referral utilization by the Since populations live in system that links the populations it serves, Dr. different social, proposed Health & -Dr. Preeti Kumar Kumar iterated: the demographic and

26 Recommendations Based on the evidence overall expenditure made to ensure that nursing graduates, to and experience shared at on healthcare, by mid-level providers, produce rural primary the consultation, the reducing as part of the PHC care nurses. following unnecessary teams, are able to Currently, the recommendations to referrals, by provide graduate training of strengthen primary preventing illnesses, comprehensive nurses and doctors health care in India and by treating primary healthcare at has a heavy urban and emerged: diseases at an earlier health and wellness tertiary healthcare stage. centers. Investments in bias. This would primary health care: PHC Team for Health 4. PHC teams should be additionally require and Wellness: adequately supported setting up of 1. The policy through regular community based commitment to 1. Responsibility (and skilling, incentives academic invest 2.5% of GDP accountability) for and supervision. departments. on healthcare, and care of a defined Appropriate 2. Allocate a large allocation of 70% of population should be technological proportion of this expenditure on entrusted to the solutions should be postgraduate seats primary healthcare entire Primary provided to help them for family-centred should be honoured healthcare (PHC) deliver quality care with rural and tracked closely. team. The team healthcare. immersion. In recent would consist of the 2. States that provide 5. These teams should years, there has been PHC staff (including lower allocations on have functional a huge increase in the Primary Care healthcare should be linkages with higher post-graduate seats Physician), and H & encouraged and levels of healthcare. (MD/ MS) for medical WC staff (consisting supported to provide graduates. Allocating of the mid-level higher allocations. Creating and them to Family provider, ANMs, retaining healthcare Medicine, with MPWs and ASHAs). Primary Health Care appropriate training Such a team is likely professionals for and National Health in rural health care to provide Rural Primary settings will bring Protection Scheme comprehensive, and Healthcare (PHCs about the change in (NHPS): continued care. and HWCs): focus from tertiary 1. People should be 2. Primary care 1. Mandate revision of care to primary care, entitled for insurance Physician should be Undergraduate and from urban bias cover under NHPS trained in Family medical and nursing to rural focus. It only when referred Medicine, and Nurses curriculum to align would require setting by PHCs. Such a (and other mid-level with rural priorities: up family medicine gatekeeping providers) trained in The training of MBBS programs in medical arrangement would equivalent generalist, should be aligned colleges, with strong help in increasing care. towards producing rural focus. utilization of PHCs 3. Appropriate legal rural family A similar shift can and maintain the physicians, and of primacy of primary provisions should be happen if large health care. It would numbers of also help in reducing postgraduate seats expenditure by for nurses are reducing allocated to unnecessary Community Health referrals. Nursing, or Nurse- Practitioner program. 2. NHPS should cover primary health care, 3. Make newly-set up in addition to the rural medical secondary and colleges responsible tertiary care. for district This would help in healthcare. A large promoting access to number of state primary health care, funded medical and also reduce the colleges are being set Conference participants and speakers at the end of the event up in district 27 hospitals, most of which on primary and high-quality training of rural healthcare are rural. Entrusting secondary care rather large number of professionals. Such a them with healthcare of than tertiary care. The professionals required group should be their respective current initiative of for managing PHCs and constituted of medical districts, focusing on District Hospital health and wellness and nursing sourcing rural students, Knowledge Centers centers. The staff of educationists and adapting their training (DHKCs) should be these training sites practitioners from curricula to meet local aligned towards this should be accorded a institutes that have a needs and helping them goal. faculty status. long experience of to be placed within the training doctors and 4. Identify and accredit 5. Set up an empowered districts would help nurses for rural areas; Rural Training Sites for group to define them fulfil their social and representatives of Rural Health improvements in accountability. In such rural physicians and Professionals. It would training, living and colleges, focus should be nurses. ensure sustained and working conditions for

28 List of Participants 1 Dr Anand Zachariah Professor CMC Vellore 2 Dr Anita Deodhar President Trained Nurses Association of India 3 Dr Anupam Hazra Public Health Student IIPH, New Delhi 4. Dr Bhavya Shah Coordinator, Health Care Aajeevika Bureau 5. Dr Chandrakant Lahariya National Professional Officer WHO India 6. Dr Chandrakant Pandav Ex-Head, Department of All India Institute of Medical Sciences Community Medicine 7. Evelyn P Kannan Secretary-General Trained Nurses Association of India 8. Dr Devendra Khandait Deputy Director Bill & Melinda Gates Foundation 9. Dr Dikshita Public Health Student IIPH, New Delhi 10. Dinesh Songara Program Officer WISH Foundation 11. Dr Elizabeth Clyma Country Director, Health Bill & Melinda Gates Foundation 12. Gayathri Sreedharan Independent Consultant 13. Dr Harish Kumar Senior Program Officer Norway-India Partnership Initiative 14. Dr Himanshu Bhushan Senior Adviser National Health Systems Resource Center 15. Hyjel D’souza Fellow Basic Health Care Services 16. Jagdeep Singh Founder Karma Health Care 17. Dr Kumkum Srivastava Director Antara Foundation 18. Dr Manu Mathur Associate Professor Public Health Foundation of India 19. Manoj Malhotra Board, Chairman Pyramid Health Care Solutions 20. Manisha Dutta Executive, Program Basic Health Care Services 21. Dr MK Bhan Patron Society for Applied Studies 22. Dr ML Jain Ex Director, Public Health, Government of Rajasthan 23. Dr N Devadasan Founder Institute of Public Health 24. Dr Neelam Kler Chief, Department of Neonatology Sir Ganga Ram Hospital, New Delhi 25. Dr Neeti Chandra Founder VIMAKR Foundation 26. Dr Prasanth Subramanian Senior Advisor National Health Systems Resource Center 27. Dr Pavitra Mohan Secretary Basic Health Care Services 28. Patralekha Chatterjee Journalist Independent/ Lancet 29. Dr Pratyush Mishra Secretary WONCA-Rural South Asia 30. Dr Preeti Kumar Vice-President Public Health Foundation of India 31. Dr Raman Kumar President Academy of Family Physicians of India 32. Dr Raj Mohan Panda Senior Specialist George Institute for Global Health 33. Dr Rajani Ved Executive Director National Health Systems Resource Center 34. Dr Rajeev Sadanandan Additional Chief Secretary Government of Kerala 35. Dr Rajesh Kumar Dean & Head PGIMER, Chandigarh 36. Rajiv Ahuja Health Economist Independent 37. Rajiv Khandelwal Executive Director Aajeevika Bureau 38. Dr Ramani Atkuri Public health Expert Independent 39. Dr Ratika Bhandari Public Health Student IIPH, New Delhi 40. Dr Sabahat Azim Founder Glocal Health Systems Private limited 29 41. Samir Garg Programme Coordinator State Health Systems Resource Center 42. Dr Sanjana B Mohan Director Basic Health Care Services

43. Dr Selva Titus Chacko Dean, College of Nursing CMC Vellore

44. Dr Subbiah Elango Ex-Director, Public Health, Government of Tamil Nadu

45. Sutapa Deb TV Journalist NDTV

46 Dr Tarun Choudhary Scientist Society for Applied Studies

47. Dr Vinaya Pendse Ex-Head, Department of Obstetrics RNT Medical College, Udaipur & Gynaecology

48. Dr Vinod K Paul Member Niti Ayog

(Besides these invited participants, a large numbers delegates of World Rural Health Conference participated in the consultation)

30 Edited by BHS Basic HealthCare Services Trust 39, Krishna Colony, Bedla Road Udaipur, India Email: [email protected] Website: www.bhs.org.in

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