How prepared is India for the nationwide launch of Ayushman Bharat on September 23? In Prime Minister Narendra Modi’s home state, Gujarat, the training of community health officers began in December, two months before the Budget announcement of the initiative termed Modicare by finance minister Arun Jaitley. And 26 health and wellness centers have quietly started providing primary healthcare since August. The health sub-center in Raslod village in the north-east district of Sabarkantha got a fresh lick of paint in July, and opened its doors to 4200 mystified residents as a health and wellness center (HWC) on August 2. Raslod’s is one of the 150,000 HWCs being set up by 2022 to offer primary care and timely referrals under Ayushman Bharat, which offers up to ₹5 lakh health insurance cover per year for hospitalization to 100 million poor families, with benefits expected to reach 500 million people. The villagers still call it sarkari dawakhana (government pharmacy), but they have noticed that the upgrade is more than just cosmetic. “There’s a doctor there every day, and he has medicines,” said Mamtaben, 25, who passes by their twice a day while herding her buffaloes.
The doctor is community health officer Abid Mansuri, 32, part of the first batch of 26 community health officers (CHO) deployed to operationalize HWCs in Gujarat after undergoing a six-month bridge course in community health. Mansuri and CHOs like him are the backbone of Ayushman Bharat because correct and timely referrals are essential for the flagship program to deliver on its promises. “Providing financial security for hospitalization does not mean promoting health. Healthy well-being is dependent on people not falling sick in the first place and that is possible only when comprehensive primary care becomes the foundation on which the health system stands. In the absence of that, it is like looking east to go west,” said Sujatha Rao, former secretary, ministry of health and family welfare. HWCs will focus on health promotion and disease prevention and management. “The health sub-centers badly needed an upgrade to ensure patients are heard, counselled and given basic medicines and treatment to take the burden off primary health centers and district hospitals. It’s a move in the right direction, provided it’s implemented as conceived,” said Dileep Mavlankar, director, Indian Institute of Public Health, Gandhingar, which is offering the certificate course in community health designed by the Indira Gandhi National Open University in Gujarat.
Mansuri is the poster child of national integration. A resident of Ramayan village in Sabarkantha district, he graduated as a staff nurse from SM College of Nursing in Bangalore, worked as a staff nurse at the Primary Health Center (PHC), Kishangarh, in Aravalli district of Gujarat before volunteering to train in community health at IIPHG. “There’s a village called Mahabharat, too. Both were named after the popular TV serials in the late 80s. People find it odd because both villages are home to a large Muslim community,” he said. On an average, HWC Raslod gets between 20 and 30 patients a day, “older people mostly coming in the morning and others at the end of the day,” said Mansuri. Apart from taking blood pressure readings and doing simple pinprick tests for malaria, diabetes and hemoglobin, Mansuri’s bridge course allows him to dispense over-the-counter medicines for fever and pain, and continue prescription medication after a Skype consultation with the medical officer at Bilasna PHC, 6 km away. He, however, cannot prescribe medication, change prescription treatment or give injections, which he is qualified to do as a staff nurse.
The doctor-patient ratio is heavily skewed in favor of urban areas. Of the 1.04 million doctors registered with the Medical Council of India or state medical councils in 2017, around 80 percent work in urban region. India’s 69 percent rural population is heavily dependent on the public health system, where the allopathic doctor-population ratio is 1:11,082, when the World Health Organization (WHO) recommends a ratio of 1:1,000. Delhi is the best served, with one government doctor per 2203 people, while Bihar is the worst, with one doctor for 28,391. Gujarat has one government doctor trained in modern medicine for a population of 11,475, as per National Health Profile, 2018. Disease prevention, diagnosis, management and referrals will also lower complications and lead to fewer hospitalizations, lowering cost of treatment for both patients and the government. “Customizing training and protocols for early management and referrals, such as for encephalitis or malaria in the endemic districts, will lower disability and deaths substantially. With funding and supervision, these health and wellness centers will be game changers not just for Ayushman Bharat but also universal health coverage,” said Tapasvi Puwar, associate professor, IIPHG. – Hindustan Times