Community-based healthcare – India

Universal health coverage (UHC) is an important part of the Sustainable Development Goals. One vital aspect of UHC is the services that are available within communities. UHC is about increasing people’s access to care that they need, and about protecting them from being impoverished as a result of healthcare. It includes a fundamental concern with reducing inequities in access.

Achieving UHC in a country is a gradual process. Over time, provision can expand to include an evolving range of preventive, promotive, and curative services, including palliative care and rehabilitation. Each country has a different starting point in terms of its disease profile, gaps in service coverage, and level of health spending. However, whatever the circumstances, community-based health services have a vital role to play in providing universal coverage.

Definitions in the area of community health services are confusing: there is no consistent global usage of the terms community-based healthcare services and community health services, i.e., all services provided by people who spend a substantial part of their working time outside a health facility, discharging their services at the individual, family or community level, as well as primary healthcare services provided in small local health facilities. The exact boundaries of the definition differ from country to country.

Persons with serious illness and their families have medical, psychosocial, and spiritual needs to be met in the community setting. High-quality programs share common foundational elements necessary to match services to population needs. Community-based healthcare is for people of all ages who need healthcare assistance at home. Community care services include home care support in nursing, physiotherapy, and other rehabilitation services.

Community-based health insurance (CBHI) is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income rural households who are excluded from formal insurance.

There are 1.4 million doctors in India. Yet, India has failed to reach its Millennium Development Goals related to health. The definition of access is the ability to receive services of a certain quality at a specific cost and convenience. The healthcare system of India is lacking in three factors related to access to healthcare: provision, utilization, and attainment.

Rural areas in India have a shortage of medical professionals. 74 percent of doctors are in urban areas, serving 28 percent of the urban population. This is a major issue for rural access to healthcare.

Out-of-pocket private payments make up 75 percent of the total expenditure on healthcare. Only one-fifth of healthcare is financed publicly. Cost of transportation prevents people from going to health centers. There is a major gap between outreach, finance, and access in India.

Without outreach, services cannot be spread to distant locations.

Without financial ability, those in distant locations cannot afford to access healthcare. Irrespective of the ability to pay, people in India increasingly seek private healthcare even for minor illnesses like cold, fever, and diarrhea. Poor housing conditions, unsafe drinking water, lack of sanitation, use of biomass fuels, exposure to environmental odds as a part of the livelihood among the marginal population group, often increase the risk of numerous health problems.

There remains a vast unfinished burden in preventing, controlling, or eliminating major communicable diseases and in bringing down the risk of deaths in maternal and peri-natal conditions. Endemic diseases arising from infection or lack of nutrition continue to account for almost two-thirds of mortality and morbidity in India.

Indeed, 11 out of 13 diseases recommended by the Bhore Committee were infectious diseases and at least three of them may well continue to be with us for the next two decades. Barring leprosy, which is almost on the path to total control, the other key communicable diseases will be TB, malaria, and AIDS, to which diarrhea in children and complicated and high-risk maternity is added in view of their pervasive incidence and avoidable mortality among the poorer and underserved sectors.

Community health impacts everything – educational achievement, safety, people’s ability to work and be financially healthy, life expectancy, happiness, and more. Health impacts every other facet of life, from a child’s ability to learn to an adult’s ability to work; so health is critical for education and financial well-being. Chronic diseases, such as diabetes and heart disease, can also increase if a community’s overall well-being is suffering. An unhealthy community tends to be obese and struggles more from chronic diseases and other health challenges. Curbing the spread of infectious diseases is also a priority of community health programs. Without them, communities may find themselves battling outbreaks of illnesses that put vulnerable populations like the elderly at higher risk. Improving community health is a huge undertaking that involves cooperation between public health workers, local government, volunteers, and average citizens alike – and the end products of their work can take a lot of forms.

Community-based health services (CBHS) are best thought of as a sub-system of the overall health system – a tier between primary facilities and communities. Without this system-wide perspective, community-based services are likely to be inefficient, with gaps and duplications in provision.

Community health services aim to improve the health and well-being of locals by:

• Encouraging people to actively participate in their own healthcare and well-being;
• Working together with other primary healthcare providers such as general practitioners (GPs) to provide coordinated care;
• Liaising with other health agencies and service providers to fill service gaps;
• Encouraging individuals and community groups to actively participate in the center’s activities;
• Promoting prevention of lifestyle-related diseases and conditions; and
• Developing healthcare programs and activities to improve social and physical environments in the community.

The services offered vary between community health services, depending on the needs of the local area. Primary health services could include:

• Counseling and support services;
• Health promotion activities;
• Medical and nursing services;
• Dental health; and
• Allied health, including audiology, dietetics, exercise, physiology, physiotherapy, podiatry, occupational therapy, and speech therapy.

Other services and supports may include:

• Aged care services;
• Alcohol and drug programs;
• Maternal and child health services;
• Mental health programs;
• Disability services;
• Outreach services;
• Rehabilitation programs; and
• Support for self-help.

New technologies offer many positive opportunities for CBHS, but it is important to have a systems perspective, given the potential for wasting money through uncoordinated and poorly managed expansion. mHealth (mobile health) has the potential to make a big difference to community-based healthcare. Whilst the location may be remote, there can be daily interaction with other health workers; information, such as diagnosis and treatment protocols, can be stored on one hand-held device and health information can be transmitted through user-friendly applications in real time from the same device. Some mobile devices can also measure a patient’s temperature, rate of breathing, and more. There are numerous innovations in technology to diagnose and treat diseases at the point-of-care, which are suitable for use in rural and urban low-resource settings.

International benchmarks have been developed that show how community-based health workers can contribute to emergency preparedness and responses. Regular training to prepare health workers for emergencies is potentially an efficient way to enhance the effectiveness of the health system as a whole in terms of its response to emergencies and disasters. Community-based health workers have important local knowledge about their communities, which is critical in emergencies.

The importance of planning for community-based services as a whole, rather than as a number of piecemeal activities, should be realized. Without this overview, there will be gaps, duplication, and inconsistencies in terms of services, and opportunities to progress toward universal health coverage will be missed.