The health care system can emulate the rules of the education system – where each lower tier prepares the child for the higher tiers and no shortcuts are allowed.
In our healthcare system, shortcuts are a rule, which is why tertiary government hospitals treat an estimated 70% of patients requiring primary care.
The plan to expand the Rashtriya Swasthya Bima Yojana (RSBY) to a higher coverage of Rs 1 lakh for a family of five is a historic step, but not integrating primary health is a grave omission.
Primary health is the filter that addresses a fundamental part of healthcare. It focuses on preventing the onset of an illness and on a simple illness from becoming complicated and life-threatening. By setting aside about 5% of the Rs 1 lakh under RSBY coverage to offer about 25 primary health and antenatal care consultations per year to each below poverty line (BPL) family will save on the remaining 95% cover.
In the past, RSBY has tried to integrate primary health — it mostly failed because of its inability to confirm delivery of services. This would mean paying small amounts to numerous providers of primary healthcare, which makes monitoring difficult. But the ground has shifted now. The use of technology by city doctors for rural patients gives fool-proof metrics as each consultation is centrally stored, making audits possible from any place, any time. The 2G SIM cards power the system by providing doctors for high-quality consultations at the doorstep of communities.
This technology can help reinstate primary health to be the non-negotiable entry point for all health care. Secondary and tertiary care can follow as the logical corollary.
Many options for telemedicine have evolved over the past five years. Medical centres run by entrepreneurs also cater to the needs of some rural segments. Once RSBY sets the output standards for these services, the same network can be used to cater to BPL families. This can encourage entrepreneurship and attract private capital.
The retooled primary health centres (PHCs) can focus on basic surgeries with RSBY-supported private clinics playing a supplementary role.
Recent findings support this approach. The Lancet Commission on Global Surgery underlined last year how 97% people in South Asia lack access to basic surgical care. Neonatal mortality — the primary villain of infant mortality — can, for instance, drop by a whopping 70% if simple surgeries can become a part of primary health care.
This means the PHCs need to provide elementary surgical services with RSBY-supported private facilities filling in for shortfalls. Tying up the measly 27,421 PHC doctors for 900 million rural population’s medical needs is improvident.
Once this system is in place, a doctor providing primary health services will determine whether the case warrants attention at secondary or tertiary care. Technology can form the backbone that connects them all and ensures supervision with reliable metrics.
It will be a pity if the efforts to ensure healthcare equity fail because we did not re-engineer the structures to deliver it.
Gopi Gopalakrishnan is president, World Health Partners. The views expressed are personal.