A challenging task

Dr Basant Potnuru
The big-bang announcement of the National Health Protection Scheme in the Union Budget 2018-19 has invited a lot of attention, curiosity and criticism. The scheme aims to provide an annual health cover of up to Rs. 5 lakhs per family to 10 crore poor families (50 crore people). Apart from a meagre budgetary allocation of Rs. 2000 crores, lack of medical infrastructure, availability of doctors, etc. are to be the major impediments towards the implementation of the scheme.
One of the serious limitations of the current Indian healthcare system is the lack of primary healthcare. Though there is an impressive architecture of healthcare institutions at the primary level, the functioning of these institutions is far below their potential due to funds deficiency, lack of infrastructure and healthcare workers. The district hospitals function as the secondary tier for rural healthcare and primary tier for the urban population. The tertiary healthcare is supposed to be provided by healthcare institutions well-equipped with sophisticated diagnostic and investigative facilities in urban areas. At all of these levels of care, given the large size of the disease burden and complete absence of primary healthcare in rural areas, the propensity of people to directly approach the district and tertiary hospitals even for relatively routine treatments is very high, leading to pushing the demand for healthcare beyond the capacities of these hospitals. Thus, there is always a massive rush and overcrowding in these hospitals causing avoidable casualties due to inadequate attention and care for each patient. The implementation of the National Health Protection Scheme will further burden these hospitals, keeping in mind absence of advanced care private sector hospitals in the backward semi-urban areas. Therefore, without fixing the problems of primary and secondary healthcare institutions, the successful implementation of this scheme at the tertiary level will remain as a pipedream.
A recent study undertaken by the author published in the Indian Journal of Public Health reveals that in aggregate there were only 4.8 doctors per 10,000 population available in India in 2014 after considering deductions from the registered stock for retirement and emigration of doctors. The study also emphasized that the country needs 1,476,000 practicing doctors in 2030 to meet a modest doctor-population ratio of 1:1000 people. This needs a whopping growth rate of 120 percent over the 2014 registered stock of doctors. Moreover, even an achievement of 1 doctor per 1,000 population in aggregate would not meet the basic requirement to ensure universal health cover in the country.
As per the Indian Public Health Standards’ (IPHS) norm to have at least one doctor in every Primary Health Centre (PHC) and 9 doctors (including specialists) in a Community Health Centre (CHC), there was a shortfall of 57,951 doctors in 2014. Even if we were able to overcome this shortfall by filling the vacant positions, our rural public sector doctor-population ratio would have still remained low at 1.2 per 10,000 population, below the WHO’s minimum norm of 2 doctors per 10,000 people.
Though improvement of rural conditions through enhancement of rural infrastructure and incentives to doctors to practice in rural areas are necessary, these measures may not be sufficient to challenge the aggregate rural shortage of doctors (or healthcare practitioners). Therefore, there is a need for an alternative arrangement for provisioning primary healthcare. A new cadre of health care workers is necessary to curb the dependence on doctors and improve access to healthcare services in rural areas.
In this direction, a three-year medical degree named as B.Sc. (Community Health) has been introduced by the Central Government in August 2014. However, due to the lack of political will to counter the opposition of the Medical Council of India and the Indian Medical Association, the course could not kick-start in the whole country. This initiative needs to be implemented on a pan-India basis to make a significant positive impact on rural health care.
An efficient primary healthcare system would ease some burden on the tertiary hospitals and its resources, and thus, can enable them to concentrate on advanced care to ensure complete health protection to needy  the  people.
(The author is Associate Professor Fore School of Management New Delhi)