Authors: Rich Feely, Boston University School of Public Health Timothy Thahane, Former Minister of Finance, Kingdom of Lesotho The article by Scott…
Author: Dr. K. Rahul S Reddy, National Coordinator, Health Systems Transformation Platform
Primary healthcare, simply put are the necessary population based and personal healthcare services that are available and delivered as near as possible to the community. The complexity is in decision making, design and implementation of primary care service package, organization of delivery and financing it. Since the Astana Declaration in 2018, discourse and experimentation on primary healthcare has gained momentum. Further accelerating the necessity during the pandemic, country health systems stakeholders are trying to address this challenge specific to their health needs and health systems context.
India has taken a leap in improving access to primary healthcare with the launch of Ayushman Bharat – Health and Wellness Centre program (AB-HWC) in February 2018. This has been a timely, progressive, and thoughtful expansion of services that were being provided in rural and urban areas under the National Health Mission (NHM). This strengthened the resolve for reaching out to provide care closer to communities as never done before. It was envisaged to have 150,000 HWCs across India by revitalizing the existing primary health centres and sub centres. These centres would be within the reach of 30 minutes of the community and provide expanded service package progressively. Broadly to ensure screening, basic management, counselling, treatment with referral linkages and follow up services to maintain care continuum. As of September 2022, about 1,15,648 HWCs are functional across India.
While this transformative program has been backed by the National Health Policy 2017, its success can also be attributed to conceptualization as a government financed program from tax revenues. And it has received Government’s commitment to allocate appropriate financial resources over the period. From the F.Y. 2018-19 to September 2021, the Union and State/ UT Government spending on the program, has been Rs. 5048 Crore (USD 618 million) with a progressive increase year on year. It is interesting to note that from allocations through gross budgetary support and the National Investment Fund in the initial years of the program implementation, the government moved on to creating sustainable channels of financing through the Pradhan Mantri Swasthya Suraksha Nidhi (PMSSN) by 2021, which is a single non-lapsable reserve fund for Health from the proceeds of Health and Education Cess. This brings this financing mechanism closer to that envisaged for achieving Universal Health Coverage, based on the principle of moving towards predominant reliance on public funding sources.
In addition to ensuring sustainable funds for the HWC program, achieving improvements in infrastructure and service provision may also have been possible because of financing arrangements that allow flexibility to contextualize care provision, incentivise performance and innovate locally. According to the scoping report of the Lancet Global Health Commission on financing primary healthcare these proved advantageous with learnings and experience with arrangements that existed since National Rural Health Mission (NRHM, 2005) and later the National Health Mission (NHM, 2013). Both these programs focused on select components of primary healthcare and actively shifted a portion of funds away from line-item budgets towards flexible pools. These pools were broadly categorised into select expenditure buckets that allowed spending at state, district, and health facility level according to need arising within the local context. Further contracting-in of health personnel and contracting out of clinical, hospitality services, bio-medical waste management and engineering services etc. through public -private partnerships was encouraged. Monetary and non-monetary incentives for health professionals, mostly doctors were provided to ensure equitable distribution in remote and difficult to reach areas. Performance linked payments were introduced based on targets for utilization of services, program, and activity outputs. Major portion of the payment to community health worker (ASHA) was variable depending on the tasks achieved while, a part of the honorarium was fixed. For the team of frontline workers and the Community Health Officers based at the HWCs, team and individual performance linked payments are being implemented.
The ability to sustain high levels of funding and implementation of responsive provider payments that incentivise performance are key for improving performance of HWCs to bring primary healthcare closer to communities, that are most in need. According to the NHA Estimates for India FY 2018-19, increasing government health and social security expenditures along with public spending of more than 50% of on primary healthcare do show promise. There is still room for experimentation. Capitation or bundled payments could be tried on pilot basis. The focus should be to incentivise quality and performance with regards to health promotion, preventive services, screening & control of non-communicable diseases and linking post-hospitalisations to HWCs for follow up care.