Resource constraints of this order are something we rarely have to contemplate in the UK, but are a daily reality in India and many other countries. Despite the differences in the scale of the resources available, the underlying challenge of improving quality within limited budgets is one shared by health systems across the world, and in the UK there has been increasing interest in the lessons that might be learnt from innovations in lower-income countries.
Having spent the past few months working at the Public Health Foundation of India in Delhi, several things have struck me about the approach taken here. One is that the health system (or at least the publicly funded part of it) has had to learn to actively involve the local community as a partner in service delivery. A second is that there are some very innovative examples of thinking creatively about human resources, in particular using task-sharing approaches to extend the capabilities of lower-cost staff.
The shortage of resources may have made these kinds of approaches necessary in India, but in both cases the lessons we can learn for the UK are as much about quality as cost.
The number and variety of linkages between the health system in India and local people is bewildering. A typical community health centre in a rural area, serving a population of perhaps 100,000 people, can act as a hub for volunteers, community health workers, accredited social health activists (or ‘ASHA workers’) and many others. Each of these is engaged on different terms and to serve distinct purposes. ASHA workers, for example, are not salaried employees but local people who receive some basic training and are given an incentive payment for performing tasks that support public health – such as encouraging parents in their village to have their children immunised against common infectious diseases. ASHA workers have been a cornerstone of efforts to improve child and maternal health in India.
As the disease burden in India shifts towards non-communicable diseases, there is interest in refashioning the role of these various community-based workers and volunteers to include provision of basic ongoing support and follow-up for people with long-term conditions, and related health promotion activities.
Back in the UK, we have previously argued that the NHS needs to become much better at strengthening these kinds of links with local communities, building on the success of initiatives such as the ‘community health champions’ programme. This is particularly important in the context of long-term conditions, for which the formal health system can only ever be part of the answer.
Exploring ways of using the workforce differently has also featured prominently in debates about the future of the NHS. In India, necessity has again been the mother of invention, with an increasing drive to use non-specialist health workers, including primary care doctors, nurses and others, in new ways.
The PRIME project, for example, is giving trained non-specialists new roles in the delivery of mental health care, as a way of answering the question posed at the beginning of this blog. PRIME is an international research programme operating in five countries that is evaluating ways of improving mental health care in low-resource settings. The team in India argues that mental health services can only be delivered sustainably if they are integrated into primary care. To achieve this, medical staff and their teams in community health centres receive training to expand their skills in detection, provision of basic psychosocial interventions and self-care advice, and referral of complex cases. Community leaders and volunteers also receive training to help build mental health awareness at the local level.
The programme involves challenging existing ways of working, and requires specialists to agree to spend a greater proportion of their time running outreach clinics in community settings and supporting non-specialist staff. The evaluation of this work is ongoing, but it should deliver lessons that will have relevance well beyond mental health – in particular around how specialist resources can be deployed with greatest effect.
Some of the challenges faced by the health system in India are, of course, very different to those in the UK. Public funding currently amounts to just 1 per cent of GDP, most health care is paid for out-of-pocket, and dramatic economic and social changes are in motion that often create as many difficulties as they solve. Nevertheless, what has struck me most is the commonality of many of the problems we face. Sharing solutions to these common problems can help us all to find ways of improving quality with finite resources.
Chris has been working with the Public Health Foundation of India while on sabbatical. He returns to The King’s Fund in June.