16 mfc bulletin/Aug 2010-Jan 2011 The conversion of the existing system into an organized system to meet the requirements of universality and equity and the rights based approach will require certain hard decisions by policy-makers and planners. We first need to spell out the structural requirements or the outline of the model, which will need the support of legislation. More than the model suggested hereunder it is the expose of the idea that is important and needs to be debated for evolving a definitive model. The most important lesson to learn from the existing model is how not to provide curative services. Across the country curative care is provided mostly by the private sector, uncontrolled and unregulated. The system operates more on the principles of irrationality than medical science. The pharmaceutical industry is in a large measure responsible for this irrationalityin medical care. Twenty thousand drug companies and over 60,000 formulations characterize the over Rs. 800 billion drug industry in India. 3 The WHO recommends about 300 drugs as essential for provision of any decent level of health care. If good health care at a reasonable cost has to be provided then a mechanism of assuring rationality must be built into the system. Family medical practice, adequately regulated, along with referral support, and implemented by a local health authority, is the best and the most economic means for providing good health care. What follows is an illustration of a mechanism to operationalise universal access to healthcare, it should not be seen as a well defined model but only as an example to facilitate a debate on creating a healthcare system based on a right to healthcare approach. This is based on learnings from experiences in other countries which have organized healthcare systems which provide near universal health care coverage to its citizens. Family Practice Each family medical practitioner (FMP) should on an average have 400 to 500 families assigned to him/her by the local health authority; in highly dense areas this Organizing the Provisioning for a Universal Healthcare System 1 - Ravi Duggal 2 number may go up to 800 to 1000 families and in very sparse areas it may be as less as 100 to 200 families. For each family/person enrolled the FMP will get a fixed amount from the local health authority, irrespective of whether care was sought or no. He/she will examine patients, make diagnosis, give advice, prescribe drugs, provide contraceptive services, make referrals, make home-visits when necessary and give specific services within his/her framework of skills. Apart from the capitation amount, he/she will be paid separately for specific services (like minor surgeries, deliveries, home- visits, pathology tests, etc.) he /she renders, and also for administrative costs and overheads. The FMP can have the choice of either being a salaried employee of the health services (in which case he/she gets a salary and other benefits) or an independent practitioner receiving a capitation fee and other service charges. The payments will keep in mind the equity principle, that is where density is high and a larger number of families are enrolled with the FMP then the per family capitation payment will be lower than in a area of sparse population where per FMP enrollment is lower, etc. The FMP will also maintain family and patient records which will facilitate both epidemiological assessments as well as evidence based planning and allocation of resources. Epidemiological Services The FMP will receive support and work in close collaboration with the epidemiological station (ES) of his/her area. The present PHC setup should be converted into an epidemiological station. This ES should have one doctor who has some training in public health (one FMP, preferably salaried, of the ES area can occupy this post) and a health team comprising of a public health nurse and health workers and supervisors to assist him/her. The ES should also function as a centre for normal deliveries and basic day care services and should have 5 to 20 beds depending on its population coverage. Each ES should cover a population between 8,000 to 20,000 in rural areas depending on density and distance factors and even up to 50,000 population in urban areas. On an average for every 2000 population there should be a health worker (subcentre of one male and one female health worker at 4000 population level) and for every six to eight health workers a supervisor. Epidemiological surveillance, monitoring, taking public health measures, laboratory services, and information management will be the main tasks of the ES. The health workers will form the survey team and also carry out tasks related to all the preventive and promotive programs (disease programs, MCH, immunization, etc.) They will work in close 1 The following discussion is an updated version based on work done by the author earlier at the Ministry of Health New Delhi as a fulltime WHO National Consultant in the Planning Division of the Ministry. An earlier version was published as “The Private Health Sector in India – Nature, Trends and a Critique” by VHAI, New Delhi, 2000 2 Email: <rduggal57@gmail.com> 3 In addition to this there is a fairly large and expanding ayurvedic and homoeopathy drug industry estimated to be over one-third of mainstream pharmaceuticals