In 2015, member nations of the World Health Organization set about achieving universal health coverage (UHC) as one of their targets when adopting the Sustainable Development Goals (SDG). UHC is defined by three components: healthcare access for all individuals and communities, comprehensive care, and financial protection.
Since access is foundational to building comprehensive and affordable healthcare, primary healthcare (PHC) is recognised as a key strategy to ensure that everyone in need of care is able to get into the system. Until recently, PHC was confined to maternal, child health, and common illnesses. However, since becoming a signatory to the global initiative to address non-communicable diseases, India has expanded the scope of PHC to include hypertension, cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes.
While new strategies and technologies are being put in place to realise the aspirations of UHC, there is an urgent need for new or changes in policies and regulations to enable such initiatives to become effective. The current, often decades’ old regulations that were relevant then, now have to undergo a paradigm shift, both to accommodate the technological advances and enable the new initiatives.
When it comes to eye care, the strategy for providing screening and some level of primary care at the community level in India (and most developing countries) is essentially limited to periodic community outreach events like eye camps, typically conducted once a year in a given community. A study done in South India in the late 1990s showed that less than 7 per cent of those who already felt they needed an eye care intervention attended an eye camp, even when it was in the same or a nearby village. On a population coverage basis, this was under 0.25 per cent, while an estimated 20-25 per cent of the general population would have some eye care need. In hindsight, it’s clear that an eye camp that happens once a year for five to six hours is unlikely to cater to the needs of all, reinforcing the need for permanent, year round primary eye care services.
My colleagues and I conducted a case study to demonstrate the feasibility and policy changes that have to be enacted to make this UHC goal an effective reality. As the first step, we broke down primary eye care conditions into case findings, treatments, and follow-ups.
With the advent of technologies like broadband, telemedicine, and low-cost imaging, we chose to set up telemedicine and information technology-enabled primary eye care centres (vision centres) with simple user interfaces.
The first vision centre was launched in 2003. Since then, 75 such centres have come up across rural Tamil Nadu, covering a population of over six million. The average population coverage is around 25 per cent — going as high as 50 per cent in older centres (half the population had visited the vision centre one or more times for some eye condition).
About 90 per cent of the patients visiting vision centres receive complete care — diagnosis, treatment advice, and medicines or prescribed spectacles. While patients pay for these, they are priced affordably and everyone receives them immediately. As necessary, some of the patients are referred to the base hospital for surgery or more advanced care.
Patients’ compliance to referrals is very high since referrals are limited to those with advanced conditions requiring surgery or specialised investigations. Here, they have the option of getting the services at the hospital at subsidised rates or for free. This combination of high coverage, addressing all eye conditions, and being affordable meets the three components of UHC.
This scaled working model of universal eye health has widespread potential and its underlying principles and technologies could be replicated across all disciplines of healthcare. Within eye care, scaling has happened across the States of Tripura, Chhattisgarh and Tamil Nadu, and quite extensively in Bangladesh.
However, several policy gaps are preventing this from being scaled to its full potential. A lot of the policies and regulations were formulated at an era when the current technologies were not present and the services were largely urban-centric. Two major policy areas, in particular, need to be addressed.
Telemedicine and remote diagnosis have been around for over a decade now and have many applications from radiology interpretation to cardiac consultation based on ECG. The governmenthas, in fact, been promoting telemedicine since 2001 with the Indian Space Research Organization providing connectivity to remote rural areas. On the other hand a lack of policy guidelines gives rise to situations such as the one reported by The New Indian Express in September 2018, in which a doctor couple who provided remote consultation was charged with medical negligence by a Bombay High Court, declaring such consultations as illegal, leading to a negative impact on the teleconsultation industry.
UHC can become a reality only through a PHC approach. And comprehensive PHC can be successful only through the deployment of digital technologies like tele-health and artificial intelligence. This requires enabling policies.
A patient’s health condition doesn’t improve unless the patient is able to get the prescribed medicines and use them as directed. When medications are prescribed for speciality conditions (like ophthalmology) at the village level, such medications are not available in local pharmacies, even if they exist, which often is not the case. The patient then has to go to the nearest town, at considerable expense and effort, to get the medication and in most instances this doesn’t happen.
As a result, the patient’s condition doesn’t improve and often deteriorates. The Pharmacy Act stipulates certain minimum physical infrastructure and qualified pharmacists to dispense the medications.
This works fine in urban settings where the scale of operations can support such staffing and infrastructure. At the grassroots level, the current regulations will obstruct patients from getting medications in a timely and affordable manner. This necessitates appropriate policy changes (such as innovations like the Nuka System of Care in Alaska).
The current policy and regulatory framework doesn’t work at the primary level, which happens at a much lower scale. Similarly, policies need to be cognisant of technological advances and their demonstrated potential, as well as redefine what staff at the primary level can do with technological support. Such changes will help drive the primary care approach, which is fundamental to achieving universal healthcare.
The writer is the Executive Director at Aravind Eye Care System (Tamil Nadu) and a CASI Spring 2019 Visiting Fellow. This article is by special arrangement with the Centre for the Advanced Study of India, University of Pennsylvania.
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