Catalysts for Change: A New Direction in Primary Care

This blog post is the first in a series about the Catalysts for Change initiative in the state of Andhra Pradesh, India. This series will follow the journey of Andhra Pradesh as the state reforms its urban healthcare system. 

Reposted with permission from Access Health International | By 

Primary healthcare is a tough nut to crack. In India, care is fragmented. A formal primary care system, well integrated with hospitals and higher levels of care, is virtually nonexistent. This lack of an integrated and organized primary care system poses special problems in urban settings. In cities, living conditions for the poor are often congested. Heavy migration into the cities results in slum conditions, with compromised sanitation and hygiene. The bulk of primary care in cities is provided by private doctors that work in small outpatient clinics or in outpatient departments of specialty hospitals.

Urban primary care is becoming increasingly hospital centric, with no proper gatekeeping system. A robust gatekeeping system functions as the first point of contact for the patient. A gatekeeping system will help the patient navigate better the complex health system, particularly when higher levels of care are required. The gatekeeping system then closes the loop by providing follow up and rehabilitative care. As the name suggests, the gatekeeping mechanism allows only those who need higher levels of care to pass through. An effective gatekeeping system brings down costs, improves doctor patient ratios, and improves accountability in the health system.

The concept of care is often mistaken for the concept of cure. In India, primary care is focused on curative services. The existing system places only minimal emphasis on wellness or on activities that promote good health. Primary care providers are paid for each service they provide. This fee for service payment model creates incentives for private providers to increase hospitalizations – to provide more care, not better care. This approach is a burden on patients, and on the healthcare system as a whole.

To build a strong healthcare system, India needs an integrated approach to care that centers on the needs of the patient. The system must be designed to provide good outcomes for patients rather than to provide a linear array of services with little or no regard for what patients need. However, the movement toward a patient centered system seems distant. This movement requires a fundamental change in the way our health systems are managed. Experiments in better primary care systems and policy changes to support better primary care management do exist within India. One such example is the “Catalysts for Change” concept currently being tested by the National Urban Health Mission of Andhra Pradesh.

Until recently, the National Health Mission program, a national program to strengthen the healthcare system in India, has focused on rural areas, through the National Rural Health Mission. Urban health has been neglected. The National Urban Health Mission was launched in 2013 to address health in urban settings. Today, individual state governments, like the government of Andhra Pradesh, are rolling out National Urban Health Missions, with support from the central government of India. The National Health Mission has been instrumental in bringing key changes to the healthcare system. It is the responsibility of the states to use the National Urban Health Mission platform to bring about transformative change in urban health.

Urban Healthcare in the State of Andhra Pradesh

About twenty nine percent of the population of Andhra Pradesh is urban. Close to two hundred primary care clinics, called urban primary health centers, currently operate in urban areas throughout the state, covering an overall population of 14.6 million. Most of these health centers run in partnership with local nongovernmental organizations. Currently, the health centers provide family planning and maternal and child health services only. This focus on reproductive and child health services neglects the diverse healthcare needs of the larger urban population. For example, this population could also benefit from healthcare services focused on the prevention and management of noncommunicable diseases and issues related to alcohol and substance addiction. The existing health centers often go underused because they fail to serve the needs of the population.

In 2014, the government of Andhra Pradesh initiated the National Urban Health Mission to transform urban healthcare in the state. The state government hoped to create a healthcare system that was accessible, accountable, and holistic in nature. As a first step, the government commissioned ACCESS Health to evaluate the existing urban primary health centers. We needed to understand the status quo of urban health in the state. We particularly wanted to understand the role of partner nongovernmental organizations in managing the urban primary health centers.

In the next blog post, we will talk about the goals of our study in Andhra Pradesh. We will share the details of how we conducted the study, what we found, and we will introduce the Catalysts for Change initiative, a government led effort to change fundamentally how urban healthcare is delivered in the state.