Primary Health Care - Lessons from Kerala

What is the issue?

• Proper systems in Universal primary health care are crucial in India for achieving Universal Health Coverage, one of the SDGs.
• The experience of Kerala in transforming primary care has lessons for the country in achieving the Astana Declaration goals.

What is the Astana Declaration?

• In October 2018, at Astana, Kazakhstan, world leaders declared their commitment to ‘Primary Care’.
• The Astana Declaration aims to meet all people’s health needs across the life course.
• This would be through comprehensive preventive, promotive, curative, rehabilitative services and palliative care.

• A representative list of primary care services are provided in this, which includes but not limited to -

1. vaccination
2. screenings
3. prevention, control and management of non-communicable and communicable diseases
4. care and services that promote, maintain and improve maternal, newborn, child and adolescent health
5. mental health
6. sexual and reproductive health

What is Kerala's experience in this regard?

• The 'Aardram mission' in Kerala aims at creating “People Friendly” Health Delivery System in the state.
• The approach is need-based and aims at treating every patient with ‘dignity’.
• In 2016, Kerala had, as part of the Aardram mission, attempted to re-design its primary care.

• In the revamped primary care, Kerala tried to provide the services enlisted in the Astana declaration and more, with mixed results.
• These services cannot be provided without adequate human resources.
• It is nearly impossible to provide them with the current Indian norm of one primary care team for a population of 30,000.
• So Kerala tried to reduce the target population to 10,000, but even this turned out to be too high to be effective.
• It thus suggests that providing comprehensive primary care would require at least one team for 5,000 populations.
• This would mean a six-fold increase in the cost of manpower alone.

What does this call for?

• Fund - Most successful primary care interventions allocate not more than 2,500 beneficiaries per team.
• But the supply of more human resources would generate demand for services.
• So there would be a corresponding increase in the cost of drugs, consumables, equipment and space.
• So the commitment to provide comprehensive primary care would be meaningful only with a substantial increase in fund allocation.
• Training - Providing the entire set of services is beyond the capacity of medical and nursing graduates without specialised training.
• Practitioners in most good primary care systems are specialists, often with postgraduate training.
• The Post Graduate Course in Family Medicine, which is the nearest India has to such a course, is available in very few institutions.
• Kerala has addressed this challenge through short courses in specific areas.
• E.g. management of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and depression
• India has to build its capacity in this regard if it is to offer services as is planned in many States.
• Data - Providers have to assume responsibility for the health of the population assigned to them and the population should trust them.
• Both are linked to capacity, attitude and support from referral networks and the systemic framework.
• It will not be possible unless the numbers assigned are within manageable proportions.
• So access to longitudinal data on individuals will be helpful in achieving the link.
• Thus, dynamic electronic health records and decision support through analysis of data are essential.
• Private sector - The private sector provides primary care in most countries though it is paid for from the budget or insurance.
• In India, more than 60% of primary care is provided by the private sector.
• It can provide good quality primary care if there are systems to finance care and if it is prepared to invest in developing the needed capacities.
• Devising and operating such a system (more fund management than insurance though it can be linked to insurance) is needed.

Source: The Hindu