This discussion theme is in continuance to our first discussion titled ‘Health System in India: Bridging the Gap between Potential and Performance’. To review what others have commented on this subject earlier in the first discussion, visit our Blog.

How can we maximize health returns through strengthening Service Delivery?

a. Access, continuum and organization of care

1. Issues

1.1. Services do not completely reach the poorest and most marginalized population groups.

1.2. The lack of networking between different levels of healthcare facilities leads to fragmentation of care, duplication and overload at secondary and tertiary health facilities.

1.3. The lack of evidence on essentiality and cost-effectiveness of possible interventions hinders smart investment decisions, and may lead to imbalance in provision of services along levels of care (primary versus secondary/tertiary)

2. Suggestions

2.1. Barriers in access to care must be identified and addressed for vulnerable population groups.

2.2. Monitoring and evaluation systems must be designed to collect disaggregated data for better decision making.

2.3. Existing Mobile Medical Units may be expanded to have a presence in each Community Health Centre as well as in specific areas that have moving populations (islands/flood plains).

2.4. Special services for vulnerable and disadvantaged groups such as counselling of victims of mental trauma in conflict areas, services for the differently-abled must be provided.

2.5. Networking of Sub-centres, Primary Health Centres (PHCs), Community Health Centres, district hospitals and medical colleges can lead to effective prevention, assessment, referral and management of patients at the appropriate level. The medical college can provide the broad vision, leadership and opportunities for skill upgradation for the network of facilities.

2.6. An Essential Health Package of services must be developed which is provided to all residents in the district itself. This package must be developed based on the criteria of essentiality and cost-effectiveness which may be ensured through Health Technology Assessment by a professional entity.

2.7. Context specific methods for increasing efficiency through innovative methods of financing, organization and delivery of health services need to be developed and evaluated. For this the implementation and evaluation of Universal Health Coverage (UHC) pilots is vital to test various strategies for the progress towards the objective of UHC.

b. Tertiary and Emergency care

3. Issues

3.1. Setting up and running of tertiary care institutions and services involves higher expenditure. If tertiary care institutes do not generate their own funds, no funds will be available to set up new institutes, or for primary care.

3.2. There are no national norms for access to emergency care, or network of trauma facilities, or assigning obligation to health facilities to treat emergency cases.

4. Suggestions

4.1. Greater autonomy may be conferred for tertiary care institutions and hospitals in operational and resource generation matters to be able to function as board managed entities, backed by accountability for outcomes. Models for self-generation of revenue include those of the Aravind eye care system based in Tamil Nadu which can be replicated.

4.2. Medical colleges should take territorial responsibility, and act as the academic guide for all professionals in their area.

4.3. Since time is a vital factor for survival in emergencies, every citizen should have access to a trauma centre through ambulance networks in a defined time.

4.4. Positioning a system for Emergency Medical Referral possibly with the Fire-Fighting Departments, as in developed countries (to be useful in disaster management and response also) may be considered.

4.5. Consider enacting a legal requirement making Emergency Medical Treatment by all hospitals compulsory regardless of status, or ability to pay. A similar law has been very helpful in preventing avoidable deaths in the USA (Emergency Medical Treatment and Active Labour Act-EMTALA).

c. Quality of care

5. Issues

5.1. There is a very low level of conformity of public health facilities to Indian Public Health Standards (IPHS)- (facilities upgraded to IPHS- 25% SCs, 21% PHCs, 25% CHCs).

5.2. There is insufficient knowledge about, as well as non-conformity to standards of care exacerbated by inadequate supervision for compliance.

5.3. Standard treatment guidelines are not adhered to among health practitioners.

5.4. Medical errors contribute to waste and adverse outcomes for patients.

6. Suggestions

6.1. All public health facilities need to be upgraded to Indian Public Health Standards in a time-bound manner.

6.2. Institutional arrangements for measuring and certifying quality standards need to be built into the design of health facilities.

6.3. Health facilities can be provided incentives for superior performance on pre-set criteria, which can be shared with the team to achieve and improve the quality rating.

6.4. Clinical audits, reporting systems for medical errors that help to identify and learn from these errors may be set up.

6.5. Research into patient safety, methods to identify and prevent medical errors as well as dissemination of information to health care providers and administrators on methods to prevent errors may be carried out.

d. Community Participation and Client rights

7. Issues

7. 1. There is inadequate involvement of the community in the achievement of health system strengthening outcomes.

7. 2. There is insufficient focus on the rights of beneficiaries/clients of the health system.

8. Suggestions

8.1. Panchayati Raj Institutions (PRIs) should be made responsible for improving public health outcomes of their area. PRIs may be encouraged to be more responsive and perform planning, delivery, monitoring and evaluation of health services.

8.2. States may make the Village Health Sanitation and Nutrition Committees as the operational arm of Panchayats in prioritizing and strengthening activities under the Health sector and its determinants.1

8.3. Incentivization of communities through awards such as Nirmal Gram Puraskar under Swachh Bharat Abhiyaan may be undertaken to increase community participation in improving health outcomes.

8.4. Adoption of accountability mechanisms that focus on community based systems such as citizens’ charter, patients’ rights, social audits, public hearings and grievance redressal mechanisms may be prioritized.1,2

8.5. There should be effective enforcement of the provisions of the Clinical Establishments Act including putting in place a Charter/ Bill of Patients’ rights as part of the Act.