Primary Care

Healthcare Innovations in India: We Need to Know More

This is the third post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we explore innovative healthcare delivery models emerging from the private sector, and how they might fit into government goals of achieving UHC and comprehensive PHC.

India’s immense socioeconomic, ethnic, epidemiological and demographic diversity creates fertile ground for innovation, and this holds true in the healthcare sector. Much has been written on healthcare innovators and novel technologies emerging from India. While the focus tends to be on affordable medical equipment, therapies and information and communication technologies, outside of the spotlight, some private healthcare organizations are unleashing pioneering delivery models to provide basic care to the poor. For our purposes, a delivery model is merely the ways in which care is provided to a person, population group or patient cohort. Understanding the roll-out process, costs and impacts of these innovative delivery models is important in light of government goals to progressively achieve UHC and to strengthen primary healthcare.

Currently, most healthcare in India is of an on-demand, curative nature, and is primarily provided by hospitals and private practitioners. This is especially the case in the ambulatory market. On one hand, public ambulatory facilities emphasize disease-oriented vertical programs and RMNCH services. On the other, private providers, who deliver over 70 percent of ambulatory care, operate on a fee-for-service basis and have few incentives to move away from the prevailing episodic model of care. Yet the changing burden of disease in India, coupled with rapid aging and urbanization, necessitate a new model in which primary healthcare takes a foundational role and there is close and regular interaction along the continuum of providers, including hospital-based professionals, primary care providers, community health workers and home care providers. Recent government directives are taking first steps toward developing such a model with an emphasis on comprehensive primary healthcare, aligned with global best practice. However, government focus tends to be inward – limited to the public delivery system, which is a relatively small player in the healthcare delivery landscape – rather than looking more broadly at the sector as a whole, and learning from innovative non-profit and for-profit players across India. 

The private sector has implemented different types of delivery models that generally aim to provide high-quality, affordable care to those at the bottom of the pyramid. For example, the non-profit CARE Rural Health Mission, which operates in Andhra Pradesh and Maharashtra, is one of many leveraging telemedicine to link trained community health workers with remote physicians at primary care clinics and hospitals. This approach helps to circumvent India’s acute shortage of trained doctors and nurses. In Mumbai, the for-profit Swasth India Medical Center (SIMC) runs a chain of health centers in the city’s slums. Its clinics provide much needed access to drugs, prevention, primary care, dental and diagnostic services, and facilitate referrals to hospitals and specialist as needed. Through smart procurement and efficiency gains from digitized patient records as well as use of standard protocols and referrals, SIMC reportedly offers affordable prices and achieves high patient satisfaction. There are numerous other examples of similar small-scale efforts with potential for scale-up.  

These examples embody the novel approaches being tested at the state and district levels as private organizations employ inventive techniques to deliver reliable, lower-cost healthcare. Yet, for all the successes, there have also been failures. E Health Points, a hub and spoke care model leveraging digital technologies and task shifting in rural Punjab, reportedly is no longer in operation Why was it unsustainable, and why have other models with similar features succeeded? Moreover, do these organizations have the performance and capacity to be contracted under the government’s PM-JAY insurance scheme to deliver a primary healthcare package to support expanded access? We don’t know.

With the exception of highly touted models such as the chain of Aravind Eye Hospitals and Narayana Institute of Cardiac Sciences, which provide specialty care for specific conditions, most of what is known about private sector delivery models focusing on the bottom of the pyramid is from landscape mapping exercises (see here and here) and descriptive case studies. Though valuable for raising awareness and introducing policy makers to these innovations, they lack details on performance, implementation processes and potential for scale-up. Without such evidence, it is difficult to replicate successes, inform policies or plug into government efforts to effectively expand coverage. The lack of evidence may be due to resource limitations and lack of capacity of these organizations to measure impact.  

These information gaps echo the data and measurement challenges innovators and social entrepreneurs face elsewhere. There needs to be a greater research and policy focus on understanding the “why”, “how” and “so what” behind India’s many innovations in healthcare delivery models, rather than just documenting the “what”. This will put government in a better position to adopt learnings and locally-tested best practices in support of its policies for UHC and comprehensive primary healthcare.

 

 

Aceso Global CTO Contributes to WHO’s Vision on the Transformative Role of Hospitals in PHC

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The WHO recently released a brief on “The Transformative Role of Hospitals in the Future of Primary Health Care” as part of its Technical Series on Primary Healthcare. It builds on two documents, “People-Centred Hospitals towards Universal Health Coverage: a WHO Position Paper” and “A Global Vision for Person- and Community Centered Hospitals in a PHC-based Health System,” both of which are in press. Aceso Global CTO Gerard La Forgia participated as a technical expert to and contributing author of these foundational documents. 

The release of this brief is timely, reflecting a growing consensus in the global health community about the fundamental role of primary care in achieving person-centered universal health coverage (UHC), and the need to rethink traditional functions of hospitals to support this agenda.

Historically, hospital and primary care systems have operated in siloes, with hospitals isolated and primarily focused on what happens within their walls, and largely absent from preventive and promotive care. The resulting care model has been fragmented, inefficient, and curative in focus, often with an outsized share of services delivered by hospitals, due in part to the lack of integration across the health system. In low- and middle-income countries (LMICs), this has contributed to distorted costs and poor quality; these systems do not serve NCDs adequately, and recent health gains and longer lifespans are being jeopardized by their failures.

The WHO Expert Group brief envisions a future of primary healthcare in which hospitals break out of their walls and actively contribute to the development of comprehensive primary care, in partnership with primary care providers and communities. New roles for hospitals will be coupled with improved hospital organization and management to raise performance, supported by an enabling institutional and policy environment that facilitates needed change. The brief outlines this vision, and touches upon pathways to transformation. The forthcoming WHO position paper provides more specifics and will serve as a resource for policymakers and planners in LMICs.

Since its founding, Aceso Global has been at the forefront of this global movement calling for renewed thinking on the roles of hospitals in people-centered healthcare systems. CEO Maureen Lewis and CTO Gerard La Forgia were founding members of and led the Center for Global Development Hospitals for Health Working Group, and have been consistent voices highlighting the key role of hospitals in reaching UHC. Aceso Global has worked in numerous countries to strengthen hospital management, raise performance, and integrate inpatient and primary care. Most notably, we provided options for a hospital PPP in St. Lucia, led the production of a Vertical Integration/Network Diagnostic and Readiness Tool for the Joint Learning Network and advised a number of countries on hospital reform, among other efforts.

This WHO brief highlights the nexus in the hospital, primary care and UHC agendas, and represents an important step forward in the global movement toward better integrated, more responsive healthcare systems.