India has one of the largest healthcare systems in the world. It is a hospital centric health system that is curative rather than preventive, designed to treat the sick rather than keep people healthy. It is a reactive health system that is costly for the payer, be it the government or individual patients. Another challenge that plagues the healthcare system is that the same disease is often managed at multiple levels of care, delaying appropriate treatment. This practice defeats the purpose of the envisioned tiered system of care, and negatively impacts health outcomes.
Growing evidence from within India and globally shows that building an integrated health system with a strong foundation in primary care can result in important payoffs. It can improve population health outcomes, ensure financial protection to citizens, enhance their experience in accessing healthcare, and provide improved value for money to the system.
Countries that have invested in primary care, within the context of a coordinated health system, have demonstrated important health and system level outcomes. In Brazil, the National Family Health Strategy was introduced as part of the Unified Health System (Sistema Único de Saúde) in 1998 with a mandate to strengthen primary care as the backbone of the health system. The Family Health Strategy reorganized healthcare delivery from facility centered, passive, curative care toward a comprehensive primary care approach. Primary care, as opposed to hospital visits, became the usual source of care for most Brazilians (from 42 percent in 1998 to 57 percent in 2008). The rate of avoidable hospitalizations decreased by 15 percent after the reform was introduced. There was a corresponding improvement in critical health outcomes, including post-neonatal infant mortality rates, and a reduction of deaths from diarrhoeal disease.
In Turkey, the Health Transformation Plan launched in 2003 was the flagship program to extend universal health coverage to the population. It placed emphasis on scaling up primary healthcare with a strong gate keeping function by primary care physicians. The program reduced catastrophic healthcare expenditures, enhanced equity of coverage and shifted care seeking from hospitals to family physicians. There was a dramatic improvement in health outcomes associated with the reform. Specifically, there was a near 50 percent reduction in maternal mortality between 1990 and 2010, and more than a 50 percent reduction in the infant and under-5 mortality rate over the same period. There was also enhanced value and efficiency in the system. With a restructured physican payment structure, under which physicians were paid on a capitation and performance basis, the productivity of physicians doubled between 2002 to 2011.
In the United States, the Kaiser Permanente integrated care model, which is based on early and effective care seeking using capitation based financing, resulted in a 20 to 30 percent shift in care seeking from tertiary to primary care, and a net savings to the program of between 15 to 20 percent.
In India, evaluations of government sponsored insurance programs have shown that many cases resulting in hospitalization can be managed at the primary care level, which would result in cost savings to the system. The World Bank recently commissioned an evaluation of the Rajiv Aarogyasri program, which was conducted by members of our ACCESS Health India team. The evaluation of the Rajiv Aarogyasri program showed a 40 percent increase in hospitalizations between 2005 and 2010 with the introduction of the program. Many of the hospitalization episodes were for minor ailments that could have been treated at the primary care level, and thus optimized resources for the system.
There is an opportunity in India to develop an integrated healthcare system that is built on a strong foundation of primary care. Such a system will ensure that most care is delivered at the primary care level, which is lower in cost and closer in proximity to the community. It will ensure universal and active population enrollment, health screening and provision of a comprehensive package of primary care services, including the management of non communicable diseases. For the population, it would mean that everyone accesses affordable and high quality health services from comparable health providers, be they in public or private sector, in an ecosystem that prioritizes prevention and wellness, early care seeking, and appropriate diagnosis and treatment.
An integrated healthcare system will require close coordination and integration between primary, secondary and tertiary level providers to ensure access to appropriate levels of care. It will also require the consolidation of financing from different national programs and risk pools to enhance coverage for the population. Through an expanded and diversified funding base and targeting of subsidies for the poor, an integrated health system can ensure greater equity in system. An integrated healthcare system will also require strong frameworks and systems for governance and quality assurance. It will need a robust information technology platform to ensure clear clinical and referral pathways, shared electronic health records and coordinated case management and financing between the primary, secondary and tertiary levels. With these features, an integrated health system can improve access to high quality healthcare for all, and have the capability to continuously track the disease burden, use of care, health outcomes and system level impacts.
This article was written with my colleagues Taara Chandani and Vrishali Shekhar at ACCESS Health India.