Ageing India Needs Better Primary Care, Universal Health Coverage

Further, 80% of the elderly are in rural India, more than half are women and 30% live below the poverty line, national data show, making it imperative for primary care systems to be strengthened and attuned to changing needs.

Non-communicable diseases are a common concern among the elderly irrespective of socioeconomic status. However, managing them requires resources that are very different from those required for reproductive and child health (RCH) and the prevention of infectious diseases, which has traditionally been the focus of health policy in India, according to Rama V. Baru, a professor and researcher at the Centre for Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi.

The ageing population requires more frequent and intense interactions with the healthcare system, and primary health centres (PHCs) can reduce the load on hospitals. Building such an effective healthcare system that works for the population requires investment in institutions and in the workforce, said Baru.

IndiaSpend spoke to Baru about health policy in India and how it needs to be reoriented to cater to the needs of a population that is faced with communicable diseases, NCDs and challenges in accessing healthcare. Edited excerpts:

What is India’s health policy landscape, specifically the National Health Policy? To what extent have the previous editions of the policy succeeded in meeting their targets?

The National Health Policy (NHP) document is a statement of the ideal, what we would like to achieve. The translation of policy into outcomes requires other inputs, and one of those is finance. I think underfinancing is a core issue in this whole thing.

The second important question that it answers is where you invested, and what vision you have for the development of health services in the country. The NHP 1983, which came after the Alma Ata conference, speaks about providing ‘Health for All’, how we need to strengthen primary care, etc. But one of the significant departures of 1983 is to say that the public sector alone cannot take care of the healthcare needs of the people, and that the private sector will be an important player.

There's a report called the World Development Report: Investing in Health. It is a complete antithesis of the Alma Ata Declaration, which talked about a comprehensive approach to primary healthcare. I think you need to see these various health policy documents in relation to the structural adjustment programme, the loans to the health sector from the World Bank, which became a major player in setting the agenda for health.

The next health policy documents are NHP 2002, and NHP 2017. NHP 2002 talks about strengthening primary-level care and it's focused on specific communicable diseases. These programmes were all funded with loans from the World Bank. At the same time, the Bank was also providing loans at the state level for health systems strengthening. Therefore, you find that these initial conditionalities that were enunciated by the World Bank were followed largely in the Indian context. Around 2002, there was a lot of emphasis on RCH, tuberculosis (TB), malaria, HIV/AIDS, etc. So whether it is the WHO, World Bank (which assumed leadership even in the health sector at that point) or bilateral aid from UK Aid or USAID or any of the other aid foundations, the agenda was set by the World Bank. The medical bureaucracy as well as the civil servants played a very important role in making India buy into this agenda.

Now, between 2002 and 2017, things changed. The NRHM (National Rural Health Mission) which came before that tried to focus on economically ‘empowered action group’ states, poorer districts, poorer states, because the health service performance was very poor and required intervention. There was an attempt to address the social gradients as well, in the form of programmes that ensure the protection of the poor. There was a lot of global critique on the World Bank's prescription for health sector reforms.

The human development issue, inequalities, and more importantly, the underperformance of health programmes became important. For the advancement of RCH or even immunisation coverage or TB or malaria control, they found that the primary level care was so weak it required secondary support, but it resulted in poor programme performance. Countries including India cut back on human resources because they were labour-intensive and required more money. Therefore you find that the 2017 document is trying to address questions around strategic purchasing, building PPPs (public private partnerships), trying to rein in the private sector to some extent but also talking about how to ensure that the supply weaknesses are addressed.

My reading of NHP 2017 is that it is a bit of a confused document. It is trying to accommodate fundamental conflicts in values between market and state. A lot of this NHP stuff is lip service. It says the right things, but the policy decisions and funding is going in a completely different direction.

Have these investments and policy enunciations translated into an improvement in public health or quality or healthcare services?

Let's separate the two, because health services improvements do not necessarily translate into health improvements.

I wouldn't say nothing has improved in the field of health service delivery. The data we have from the NRHM's intervention shows you that some states did improve on that front. Odisha is one example. That also has to do with the fact that the nature of Indian governance was federal. The Biju Janata Dal was in power in Odisha during the NRHM time, as was a forward-looking medical bureaucracy. So they managed to use the funds from the NRHM to invest and innovate at the primary level care in Odisha. In the neighbouring state of Bihar, the story was very different.

I think it would be difficult to say that there was no improvement. There were some improvements in some states. Some states that were already doing better also improved. Tamil Nadu is an example of one such state. In Kerala, they had problems with the weakening public sector, but the left-front government tried to use whatever central funds they had to improve. Rajasthan started the Jan Aushadhi programme, which is now touted as a central programme. However, control of the private sector in secondary and tertiary care just hasn't happened. The private sector is a rogue private sector, and we saw its rogue behaviour during Covid-19.

On health improvements, some of the data suggests that we have improved the infant mortality rates, child mortality rate, etc. However, all-India averages mask inequalities. We need to know if this improvement is across the board, across the social gradient improvement. The data actually shows us that it is not quite so. When you consider the marginalisation factor of minorities, scheduled castes, scheduled tribes, poorer Muslims, Dalit Christians, and you intersect it with income, you find a certain unmoving picture. We need to understand it using concepts from sociology because the NFHS (National Family Health Survey) doesn’t tell you very much.

Were the improvements in child mortality rate and infant mortality a consequence of public health policy or economic development in general?

Let me take this in two parts. One, that the improvements of health status in India also had a lot to do with a long period of concern with reproductive and child health out of concern that India was becoming too populous. The RCH introduced incentives. Even today, if you look at the incentive structures of ASHAs (accredited social health activists), the RCH gets a much higher amount of money as compared to others. The RCH was aimed at promoting institutional deliveries and ensuring child survival. Then there was the Pulse Polio programme which depleted the energies of the health service system to achieve its targets.

Now coming to the role of economic development in health, I think we also need to look at the distribution of wealth. The US model doesn't believe in progressive taxation at all. The Nordic countries, countries in East Asia, Japan, and Korea, etc. have very high welfare spendings. This is done through progressive taxation, which gives the government enough money to invest in welfare. That welfare then promotes economic development, inequities get reduced, so the social gradient issue gets sorted out. In India, there was a class who got very, very rich post liberalisation and an aspirational middle class which also got richer. However, as you go down the social gradient, those improvements were not as dramatic wealth-wise or health-wise compared to that observed in these two classes.

You said this improvement was partly a result of our investment in reproductive and child health. Can we make the transition from investing largely in the health of children towards investing in the health of the elderly?

If you have a comprehensive understanding of population health, it's not as if you can say, I will take better care of my elderly now compared to my younger. If you have a good, strong, well-functioning, universal public health system, then it should be able to address the multiple needs of the population. By privileging one set of population, you're diverting the energies of the health services away from the needs of the general population.

Within a decade, we are going to have a serious issue dealing with the needs of the elderly. This is tricky for any country because as people age, they have multiple chronic conditions that require intensive interaction with both the medical care and the healthcare system. The South East Asian countries will tell you that as their populations aged, the stress on the health system became very acute because hospitalisations increased. Every time someone has a problem, they run to a hospital because there is no primary level care that will address their problems. They have all had universal health insurance, but that completely busts their fiscal investments because by running to the hospital every time, they are actually escalating costs. What they are doing as course correction is important for us. They're rebuilding primary-level care and increasing preventive screening. So the primary level care becomes like a gatekeeper and ensures that just because you have government insurance, you're not running for every little thing to a tertiary hospital.

This should become a driver for us to move towards more comprehensive healthcare and a universal health insurance scheme. In Ayushman Bharat, the targeting [of benefits] is a huge problem because it only takes care of those below the poverty line, but what about people just above the poverty line? They can be driven into poverty because of an illness. There are catastrophic expenditures even in the middle class, for diseases like Covid-19 and cancer because they don’t even have a private insurance cover. What about the old? What about the active young? We talk about the demographic dividend, but are we doing anything to protect the health of the working population?

You mentioned that as populations age, the interactions with the healthcare systems become more intensive. What does that mean? And what are the national-level programmes that need to be strengthened to cater to these needs?

Hypertension, diabetes, musculoskeletal disorders, etc. are chronic degenerative diseases, which means that once they start, the disease progresses as the patient descends into a more degenerative state, which may require hospitalisation but at the same time not be amenable to hospitalisation. This means that the burden of care of these diseases falls at home. They may have caregivers in the family, or hire help. They may need physiotherapists, etc. Then there are cancers, which people become more prone to with age.

The shift from communicable to noncommunicable diseases (NCD) was complete in the West and almost complete in the East Asian countries. Their mortality from communicable diseases declined, but their NCD burden increased. In East Asia, they feel that investing in screening of populations is a better option so that NCDs are detected and managed earlier. They are starting to screen younger people, starting from the age of 40 years, for cancer, hypertension, diabetes and a range of NCDs. We in India have a NCD programme, but the primary healthcare system is just not equipped to handle its complicated demands. If you are diagnosed as a pre-diabetic, a lot of the responsibility to keep it monitored lies with you, which means that you have to get periodic blood tests done. So NCDs require active monitoring, whereas communicable diseases are symptom-related.

The other challenge that we have which the East Asians don’t have is that we have comorbidities. In India, a person can have TB and diabetes. That is a huge challenge, because they have to get treated for TB and take drugs for the comorbidities, and very often, we don’t know how the drugs will interact. For the clinician and public health people, it is a challenge.

For communicable diseases, the symptoms speak. For NCDs, a patient may be asymptomatic. They will only go to the doctor if they are uncomfortable. In PHCs, oftentimes, there is no full-time doctor, laboratory or laboratory technician. The people running it will tell you “jaao private main karwa lo” (go get it done in a private facility). The symptoms of people with comorbidities will not even be picked up without the attention of these professionals.

What would you say are the top five requirements in a PHC to be able to detect NCDs and the co-morbidities in terms of the skill mix?

A PHC would need a team consisting of doctors who understand NCDs, nurses and lab technicians because you need monitoring of parameters. They also need a very strong link with the family and the community, because we can't dump everything on the ASHA. Maybe in some way it can also involve the ANM who is currently seen as useful for RCH only. We need to diversify the skill mix.

They also need a link worker, that is somebody who is able to keep in touch with the patients. In some states, they used mobile phones to remind people to take their metformin regularly for diabetes control, etc. However, NCD monitoring is very labour-intensive.

A good referral system also needs to be in place. What if somebody develops a diabetic ulcer on their foot? Primary level care may not be able to treat it. They would have to go to a secondary-level facility, get it surgically treated, and then there is the follow-up and all that. It's a nuisance for people who suffer from it, and it's a real challenge for the health service system.

The biggest tragedy is that we overlook the importance of a secure human resource. We have contractualised across the board, so in every state that you go to, doctors and nurses are on contract. There is no solidarity of work, or an institution with a “we feeling” as we say in sociology, and that is not good.

The ageing of our population in an underfunded healthcare system will coincide with a deteriorating environment, increasing pollution, climate change, etc. How will this complicate the challenges?

To begin with, among the elderly population, there will be more complicated, serious kinds of conditions. Covid-19 gave us a window into that. People with multiple morbidities had a higher risk of dying or had a much more serious Covid-19 impact. We will also see a downward shift in the age of onset of many of these NCDs. Already we see young people get NCDs.

However, it’s not just climate change and the environment; it also has to do with the habits of the upwardly mobile middle class. The food we eat, the choices we make, the exercise we get. I know that the younger generation is getting conscious about it, especially the middle and upper middle classes, so we see people doing more of yoga or other forms of exercise, gym culture, etc. That is important because if you start taking care of yourself in your 30s, you may still get something, but the management of it becomes a little less problematic.

Asthmatic disorders in children are clearly related to the climate and the environment. The treatment of it begins when the patient is a child under the age of seven. Someone who is already on Asthalin (a drug used to treat asthma and chronic obstructive pulmonary disorders) and nebulisers as a child, what is the state of their lungs as they age? It makes them more prone to COPDs, TB, etc.

Is dental health a priority of the public health sector?

As people age, their gums recede, their teeth fall out and decay, etc. They require an orthodontist, which is another sub-specialisation, because their teeth will fall off. They need dentures and all kinds of other cosmetic surgeries. However, dental health policy has never been taken seriously by the public health sector. Notionally they say that even in PHCs and community health centres, there should be a dentist. However dentist training and employment is in the private sector. Firstly, the vacancies don't come up in the public sector. No dentist wants to go sit in some remote village where there is no money to be made. They’d rather settle in peri-urban, urban areas, start a small clinic or group practice. So they are either employed in the private sector, but it's not as if they make a lot of money. I have several students who have come to get a Masters in Public Health after doing a Bachelor of Dental Studies (BDS). They say there are no jobs after BDS, and not all of us can afford to set up a private practice.

How would we address the needs of our population in the next few decades?

First, increased financing, and I think we need to evolve a much more comprehensive approach to it. My greatest critique of this government is the targeted programmes. This is what I call welfare populism, which completely robs you of the opportunity to build comprehensive health services. It gets too politicised, so the people who implement it get visibility, but it erodes the fundamental concerns about financing a public health service system with adequate human resources.

Next is, we need to be able to attract the middle class to come in and use the public sector facilities. The public health services are now seen as something for the poor, and the middle class has exited from it. They may occasionally go to AIIMS because they find a very good specialist there. Will they go to a PHC or an urban PHC? A mohalla clinic? If we don't bring the middle class back, there will be no voice for good quality care. You see, till my generation, the middle and upper middle classes were still engaging with public institutions. But once my generation retires, the kinds of people who are choosing to come into these institutions are largely from lower-middle class backgrounds. There is now a belief that public healthcare is meant for the poor. You need that mix of different class backgrounds among the providers and users of services. Only then there is this sense of social solidarity, there is a belief that it belongs to all of us.

Now, what has been perpetuated successfully is “garibon ko de rahe hain” (we are giving to the poor). What we are giving to the poor is of poor quality. If they ask for better quality, we say, “tumhara kya haq hai puchne ka” (what right do you have to ask). This view of welfarism as charity or largesse exists even among providers that look at these poor people.

The only way I see it working out is by going back to the ideas of Alma Ata, of comprehensive healthcare, which will address the preventive, promotive, curative and rehabilitative needs of the population.

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