Daily The Hindu Editorials Notes – Mains Sure Shot (07/09/2019)

GS-2 Mains 

Question – Comment on the primary  health care system in India and suggest the way ahead.(250 words)

Context – The deteriorating condition of Primary health care providers in India.

What is primary health care?

• It is the first contact a person has with the healthcare system when they have a health problem.
• A general practitioner is a primary health care provider and so are nurses, pharmacists and allied health providers like dentists.

The condition of primary health care in India:

• To speak plainly the condition of primary healthcare system in India is far from good.
• People are directly going to specialists for check up in even minor illnesses like fever than to primary health care units.
• The attitude that non-allopathic doctors are nothing but ‘half-baked-quacks’ is gaining prominence, and the attitude of skipping the primary health care provider and going straight to specialists has even percolated to the poorer sections who can barely afford their fees.

Primary Health Care- A Case Study- India and Japan

Japan:

• Initially in the early part of Japan’s history of modern medicine, the access was limited to an affluent few. The common people of Japan found  it difficult to afford treatment with modern medicines.
• So the Japanese government took a few steps to bring things in order. For example, it reduced its funding to hospitals. This made treatment in hospitals even costlier without much state subsidy. So the common people and even a section of the affluent class had to turn to primary healthcare providers for treatment. This led to the primary healthcare system flourishing and getting better. Hospitals were mostly reduced to the functions like training medical students and treating infectious cases.
• The government also took steps to prevent the growth of any kind of nexus between doctors in private clinics and doctors practicing in hospitals.
• Simultaneously with the status of primary healthcare improving as a result of these measures, a strong lobby of clinic-based PCPs (primary care providers) evolved.
• The Japanese Social Health Insurance was also implemented in 1927, and the Japanese Medical Association (JMA), then dominated by PCPs, was the main player to decide the fees of the insurance.

India:

• In India on the other hand a ‘hospital-oriented’, technocratic model of health care developed.
• When we say hospital-oriented we mean people going to hospitals for treatment than primary health care clinics.
• This was done through government allocating huge funds for building urban hospitals. This was given more priority over primary health care.
• Along with this another culprit was the unregulated dual-practice system i.e.  doctors practising both in public and private sectors simultaneously. This system allowed these dual-practicing doctors very affluent, influential and powerful group held together by coherent interests.
• This influential doctors’ community which saw a lucrative future in super-specialty medicine, buttressed the technocentric approach (i.e.system of governance in which decision-makers are selected on the basis of their expertise in a given area of responsibility, particularly with regard to scientific or technical knowledge).
• So the specialists in any medical field became the main decision takers and hence they also started being the most sought after doctors.
• Following all this the primary health care providers gradually faded out of prominence. People started going to specialists more, even for general issues than to primary health care providers or primary health care clinics.
• While this was going on there was the emergence of a thriving middle class who had the money to spend on these speciality clinics even for minor treatments.
• This trajectory of events has had an enormous impact on the present-day Indian health care.

The present scenario:

• In our country the craze for ‘high-tech’ medical care has even percolated to even the subaltern section, which lacks the means to pay for such interventions.
• Health insurance schemes of the government like Ayushman Bharat also focus on providing insurance to the poor largely for private hospitalisation — when the most impoverishing expenses are incurred on basic medical care.
• This is partly influenced by the passionate popular demand for the so-called high-quality medical care and bespeak the deformity in the health-care system today.
• the landmark Bhore Committee report (1946), highlighted the need for a ‘social physician’ as a key player in India’s health system. But it was only 37 years later than ‘family medicine’ was established as a separate branch in medical studies in which one could acquire speciality.
• The highest professional body representing doctors in this country, the Medical Council of India (MCI), itself is dominated by specialists with no representation from primary care. Though there is a proposal to replace the MCI with a National Medical Commission (NMC) having representatives from primary care sectors as well, but without sensitisation of the people the situation is unlikely to be much different with the new organisation.
• The government has now decided to provide  training to mid-level health care providers under the NMC Act 2019. But the way it is being opposed is an example of how the present power structure is inimical to primary health care.
• Similarly, despite the presence of evidence proving that practitioners of modern medicine (say medical assistants) trained through short-term courses, like those of a 2-3 year duration, can greatly help in providing primary health care to the rural population, any such proposal in India gets robustly opposed by the orthodox allopathic community.
• Proposals to train practitioners of indigenous systems of medicine, like Ayurveda, in modern medicine are also met with similar opposition.

So what can be done/ way ahead:

• Firstly, people need to be sensitised and the myth that the non-allopathic practitioners are good for no use or ‘half-baked-quacks’ needs to be broken. Examples of people who get well through non-allopathic treatment should be highlighted. It it should be taken utmost care that this should not end up promoting superstition.
• Second, the examples of countries like U.K. and U.S.A. should also be highlighted who are consistently training paramedics and nurses to become physician assistants or associates through two-year courses in modern medicine.
• Further we must learn from many countries, including the U.K. and Japan, who have found a way around this by generously incentivising general practitioners (GPs) in both pecuniary and non-pecuniary terms, and scrupulously designing a system that strongly favours primary health care.
• we need to find a way to adequately empower and ennoble PCPs and give them a prominent voice in our decision-making processes pertaining to health care. 
• Also very importantly  a gate-keeping system is needed, and no one should be allowed to bypass the primary doctor to directly reach the specialist, unless situations such as emergencies so warrant.
• The attitude of people to directly move to specialists even for minor illnesses bypassing the general physicians or primary health care providers needs to be stopped. Also the attitude that the doctor who charges more fees is better needs to be checked.