States could do better than Kerala

States that take advantage of the primary care strengthening initiative will be able to avoid the consequences of not doing so currently seen in Kerala

States like Bihar and Uttar Pradesh have a lot to learn from Kerala   — both in terms of what the latter has been successful at, notably, the improvement of the social sector, social mobilisation and the promotion of tourism and in what Kerala has not been successful at, notably, control of non-communicable diseases (NCDs).

Indeed, among all Indian States, Kerala is the most affected by NCDs, such as hypertension, diabetes, cancer among others. According to Disease Burden Study 2017, NCDs accounts for nearly 75 per cent of Kerala's total disease burden. This high share of NCDs is explained by the fact that a Keralite, on an average, lives longer than an average Indian from any other State. In fact, with a life expectancy of 78.8 years for females and of 73.8 years for males, Keralites have the highest longevity. This has resulted in the highest share of the elderly population (12.6 per cent per 2011 Census) in the State's total population. But this is only a part of the explanation for the rising NCDs burden in the State.

The other part is that Kerala didn't pro-actively check the rising burden of NCDs early enough through a strong primary care intervention. It is well-known that an early detection and control of risk factors of NCDs at primary level is much more efficient and effective as it saves resources and generates better health outcomes. This is at the health system level. At the individual level, it prevents unnecessary pain and suffering and thereby contributes to improving the quality of life of individuals even at old age.

Compare Kerala's reality with the situation prevailing in States of Bihar, Jharkhand, Rajasthan and Uttar Pradesh — all have lowest burden of NCDs. The share of NCDs in the State's total disease burden is 47.6 per cent in Bihar, 48.3 per cent in Jharkhand, 49.3 per cent in Rajasthan, and 47.9 per cent in Uttar Pradesh. Life expectancy in each of these States is on the lower side; and so is the share of elderly population (age 60 years and above) in the State's total population. However, this situation will not remain the same for too long. With rising economic prosperity, these States will see rising life expectancy and greying of population. Along with it will come lifestyle diseases. These States need to be better prepared to keep an early check on the rising burden of NCDs — something that Kerala missed doing.

Because Kerala didn't put in place a strong intervention for NCDs at a primary level, it has to now treat those cases at the secondary level, which is costly. Resultantly, healthcare spending in Kerala stands at Rs 6,231 per-capita, which is the highest among the Indian States (National Health Accounts, 2017).  Treatment for NCDs and their target organ diseases is very expensive. Except for the treatment of cancer, Kerala is not able to meet the demand in the Government sector. The number of catheterisation laboratories, cardiothoracic surgery facilities, stroke management centres are mostly in private hospitals.

With gaps in the public healthcare delivery system, people are increasingly turning to private hospitals where cost of treatment is substantially higher. It comes as no surprise that private out-of-pocket health spending at Rs 5,023 per capita is the highest in Kerala (National Health Accounts, 2017). This is despite the fact that Government health spending in Kerala is significantly higher (at Rs 1,208 per-capita) than the national average. Thanks to the Union Government's initiative of reorienting primary healthcare system to check the rising burden of NCDs, Kerala, like other Indian States, is only beginning to take advantage of this opportunity which is available to all States. Those with lower burden of NCDs will stand to gain significantly more if they move rapidly to reorient their primary care system.

The major piece of primary care strengthening is converting nearly 150,000 health sub-centres (HSC) that provide selective primary care in the country into health and wellness centres (HWCs) aimed at providing preventive and promotive services as well as comprehensive primary care, including early diagnosis and control of risk factors of these chronic diseases. Each of these centres are to be operated by a well-trained mid-level provider — can be a nurse practitioner or a community health officer — who will be supported by a team of frontline health workers such as Auxiliary Nurse Midwives (ANM), Accredited social health activists (ASHA), and Multipurpose Workers (MPW). For higher level of care, HWCs will refer patients to Primary Health Centres and Community Health Centres (CHC) that will also be strengthened in a phased manner.

Trained work force is an important component of the HWC’s roll out. If the State and district health administrations can get their acts together in hiring additional workforce and get them trained, they can rapidly operationalise the HWCs. Putting other pieces of the intervention together, though difficult, is relatively straightforward.

Undoubtedly, rapidly operationalising of HWCs pose some challenge. States that are able to deal with this challenge will be able to avert a much bigger challenge which is far more complex — requiring multi-specialty skills and sophisticated equipment to dealing with burgeoning cases of NCDs in hospital setting — and far more expensive. States that are able to take advantage of the primary care strengthening initiative will be able to avoid the consequences that Kerala is currently having to deal with. Poorer States need to learn from the mistakes that Kerala made.

(The writer is a development economist, formerly with the Bill & Melinda Gates Foundation and the World Bank)