Flipping the pyramid: Renewing focus on primary care, Express Healthcare

The primary healthcare system in India faces several key challenges: a fragmented delivery system, with public and private providers operating in distinct spheres; disease control programs organised in vertical silos; and primary, secondary, and tertiary levels of care fractured from one another. Like in many other countries, healthcare delivery in India is organised from tertiary care to primary care, rather than the other way around.

For over a year, states and advisors to the governments have been working on designing a transformative primary healthcare model that can be customised for different states within local contexts.

The features that distinguish this model from the status quo include:

• Universal enrollment and proactive management of population health;

• Provision of comprehensive primary care services by a multi professional team of health workers;

• Introduction of capitation and performance based financing to shift focus from inputs to outcomes; and

• Creation of autonomous and accountable structures to govern, finance, and provide health services.

The most distinct aspect of this model is that it engages a nongovernmental agency to manage the system. The system manager will be supervised by government authorities and be held accountable for the professional management of primary healthcare services for a defined geography. The model may be customised from state to state, but it is defined by a unifying set of objectives: to increase population access to high quality healthcare, to reduce out of pocket payments, and to improve health outcomes.

Several key strategies can help ensure the success of the model as it is implemented in the states:

• Ensure clear and measurable benefits of the programme

To achieve this change will entail raising awareness, delivering high quality services, and monitoring and acting on customer feedback. This means that the system manager should creatively engage communities and raise awareness, and state governments should promote the program.

• Structure the contract as a risk sharing partnership

Many public private partnerships are designed as outsourcing contracts. However, partnerships should entail shared risks and responsibilities, and a common long term vision. In this model, the system manager will share risk and manage the health of the population through a capitation based payment structure. The risk will be limited and capped, given the unknown disease burden, use of care, and cost of delivery. In addition to receiving a base per capita payment, the system manager will be compensated for achieving high quality outcomes, for demonstrating value rather than volume alone.

• Create a roadmap to integrate with secondary and tertiary care

Ideally, primary care should be conceived as an integrated component with secondary and tertiary care, from an access, quality, and cost point of view. A few states in India are starting to discuss experiments that link primary care with insurance. The intent is to ensure universal access to primary care, though many insurance programs are reserved for below poverty line populations. The long term vision is to integrate management and funding across levels of care and giving incentive to the system managers to focus on prevention, early diagnosis, effective treatment, and a consequent reduction in hospitalisation.

• Develop a plan to reach scale and to exit

The plan should be to scale up and exit. Part of the design of this model includes building the capacity of state governments to take over from the system manager. It is unrealistic for the private sector to assume full responsibility for providing care in the public system. A mixed healthcare system should be the road ahead.

Many patients can be managed at the primary care level. We need to strengthen the base of the pyramid so that the more expensive secondary and tertiary care are only accessed through references from primary healthcare providers. It is time our policymakers ponder the inverted pyramid of healthcare services. I expect that the Fiscal Budget 2016 – 17 will include more focus on improving primary health parameters within the available means. This focus would imply that more attention will be paid to health financing, through a mix of central and state government funding, and to finding innovative ways to provide improved health benefits to economically weak and challenged strata of the population.

This article originally appeared in Expressed Healthcare, a leading publication in India.