- According to WHO, Comprehensive Primary health care ensures people receive care – ranging from promotion and prevention to treatment, rehabilitation and palliative care – as close as feasible to people’s everyday
- Comprehensive primary care also includes systematically addressing the broader determinants of health (including social, economic, environmental, as well as people’s characteristics and behaviours) through evidence-informed public policies and actions across all sectors; at the same time, empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being.
- As recognized in the 2018 Astana Declaration, Primary Health Care (PHC) approach is the most effective way to sustainably solve today’s health and health system challenges. PHC system can tackle up to 80% of health needs and can reduce the need for specialized health care
In this context, the paper will aim to analyze India’s Comprehensive Primary Care situation ranging from the time of independence to the present scenario. It will also highlight the policy measures adopted by the Government, challenges faced by it and suggest a way forward.
COMPREHENSIVE PRIMARY CARE IN INDIA
- Evolution of primary care
During the period of independence, India’s Health Care system was abysmal, it was realized how Comprehensive Primary healthcare was needed, to be the backbone of health service delivery. Hence, the need for and emphasis on strengthening Primary Health Care was first articulated in the Bhore Committee Report in 1946. India, was one of the first countries to recognize the merits of primary healthcare approach. Long before the declaration of Alma-Ata, India adopted a primary healthcare model based on the principle that inability to pay should not prevent people from accessing health services. With beginning of health planning in India and first five-year plan formulation (1951-1955), Community Development Programme was launched in 1952. It was envisaged as a multipurpose program covering health and sanitation through establishment of primary health centers (PHCs) and subcenters. Rural Health Scheme was launched in 1977, wherein training of community health, reorientation training of multipurpose workers, and linking medical colleges to rural health was initiated. The Alma-Ata Declaration of 1978 launched the concept of health for all by year 2000. The declaration advocated the provision of first contact services and basic medical care within the framework of an integrated health services. Alma-Ata declaration led to formulation of India’s first National Health Policy in 1983. The major goal of policy was to provide universal, comprehensive primary health services. Nearly 20 years after the first policy, the second National Health Policy was presented in 2002. This policy set out a new framework to achieve public health goals in socioeconomic structure currently prevailing in the
country. It set out an increased sectoral share of allocation out of total health spending to primary healthcare.
Recognizing the importance of health in the process of economic and social development and improving the quality of life of our citizens, the Government of India launched the National Rural Health Mission in 2005 to carry out necessary architectural correction in the basic healthcare delivery system. The goal of the mission was to improve the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women, and children.
- Existing Primary health care
The provision of Comprehensive Primary Health Care reduces morbidity and mortality at much lower costs and significantly reduces the need for secondary and tertiary care. For primary health care to be comprehensive, it needs to span preventive, promotive, curative, rehabilitative and palliative aspects of care. Primary Health Care goes beyond first contact care, and is expected to mediate a two-way referral support to higher-level and ensure follow up support for individual and population health interventions.
Learning from its past experiences in health policy, the government in 2017 launched The National Health Policy, that aimed to strengthen the delivery of Primary Health Care, through establishment of “Health and Wellness Centres” as the platform to deliver Comprehensive Primary Health Care and called for a commitment of two thirds of the health budget to primary health care.
As per the recommendation of the NHP 2017, in February 2018, the Government launched its flagship scheme; Ayushman Bharat with two components under it; HWCs and PM-JAY. It was announced that 1,50,000 Health & Wellness Centres (HWCs) would be created by transforming existing Sub Health Centres and Primary Health Centres to deliver Comprehensive Primary Health Care. This was the first step in the conversion of policy articulations to a budgetary commitment.
The other component of Ayushman Bharat, namely the Pradhan Mantri Jan Arogya Yojana (PMJAY) aims to provide financial protection for secondary and tertiary care to about 40% of India’s households. Its success and affordability rests substantially on the effectiveness of provision of Comprehensive Primary Health Care through HWCs. Together, the two components of Ayushman Bharat will enable the realization of the aspiration for Universal Health Coverage.
Another recent development towards Primary Care is the $300 million loan provided by the Asian Development Bank to strengthen and improve access to comprehensive primary health care to the urban areas of India. The Strengthening Comprehensive Primary Health Care in Urban Areas Program will support the Ayushman Bharat Health and Wellness Centres to ensure equitable access to quality primary health care services in urban areas of 13 states including Andhra Pradesh, Assam, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu, Telangana, and West Bengal.
Some of the key challenges faced by India in terms of comprehensive primary care are listed below
- Insufficient infrastructure and manpower: According to Rural Health Survey 2011, as on March 2011 there were 148,124 subcenters; 23,887 PHCs; and 4,809 community health centers functioning in India. The norms set for the population coverage for subcenter, PHC, and CHC for plan areas are 5,000; 30,000; and 120,000; respectively. As on March, 2011 the overall shortfall in the posts of health worker (female (F))/auxiliary nurse midwife was 3.8% of the total requirement. Overall, there was a shortfall of 63.9% specialists at the CHCs as compared to the requirement for existing
- Expanding population: Catering to the Primary Health Care of the world’s second highest populated country is one of the biggest challenges. In the hard count during 2017, 1.33 billion of Indian population is being served by 1.8 million registered medical graduates. So, the ratio is 1.34 doctor for 1,000 Indian citizens which is highly
- Demography of the country: Within the next few decades, we will see an extraordinary increase in the number of older people in the country. The public health benefits of preventive medicine in old age comes from the compression of the time spent in dependency to a Thus, there will be a pressure on the Comprehensive Primary healthcare infrastructure to cater to such a huge population of the aged.
- Societal concerns: Patients often complain of rude and discriminatory behaviour of health workers who discriminate against women and minorities from scheduled castes and scheduled Also, for the better off sections of the society, free preventive care from Government’s Wellness centres attracts social stigma. The trend of increasing urbanization is another cause of concern in this regard.
- Client Satisfaction: It has been observed that there is poor level of client satisfaction in rural as well as urban areas with regard to the primary healthcare services. Client satisfaction is an important measure of the quality of healthcare and needs to be addressed in order to improve the utilization of primary healthcare
There is a vast scope for the development of India’s comprehensive primary care ecosystem,
some of the recommendations are listed below;
- Enabling Preventive Care: In order to promote preventive care, the Union government has announced the conversion of primary health care centres into Health and Wellness Centers (HWCs).
- These HWCs will act as the pillar of preventive care and ‘gateway’ for access to secondary and tertiary health services. Thus, there is a need to accelerate the establishment of a network HWCs, for this extra funding through Corporate Social Responsibility (CSR) can be
- Bringing Behavioral Change: There is a need to ensure people eat right, sleep right, maintain good hygiene, exercise, and adopt a healthy lifestyle that necessitates concerted interventions at various levels of the
- In order to catalyze people’s participation for healthy India, there is need for Swasth Bharat Jan Andolan on lines of Swach Bharat Abhiyan as well as the proper implementation of the Eat Right India
- Cooperative Federalism: Given the major role that States have to play in creating strong health systems across the country, allocations provided by the Finance Commission can become the critical catalyst for transforming the nation’s
- State governments should be incentivized to invest in creating a dedicated cadre for public health at the state, district and block
- Improved infrastructure and Funding: Public funding on health needs to be increased to at least 2.5% of GDP as envisaged in the National Health Policy, 2017 for the development of infrastructure and manpower in the primary health
- Promoting digital health ecosystem: with the advent of the National Digital Health Mission, primary health care can be now provided virtually. Several Start-ups are investing in the digital healthcare sector from process automation to diagnostics to low-cost innovations.
It can thus be concluded by saying that while primary health care is the only affordable and effective path for India to Universal Health Coverage, emphasis should also be laid upon the structure and processes that are required in health systems to enable Comprehensive Primary Health Care (CPHC). The delivery of CPHC through HWCs rests substantially on the institutional mechanisms, governance structures, and systems created under the National Health Mission (NHM). NHM, as part of health system reform in the country, in its nearly 12 years of implementation, has supported states to create several platforms for delivery of community-based health systems, expanding Human Resources for Health and infrastructure towards strengthening primary and secondary care. Although the delivery of universal Comprehensive Primary Health Care, through HWCs builds on existing systems, it will need change management and systems design at various levels, to realize its full potential.
Thus, it can be said that the success of primary health system exists in tapping the existing potential and making appropriate structural changes. Moreover, the role of comprehensive primary care should not be defined in isolation but in relation to the constituents of the health system.
- Official Website- Ministry of Health and Family Welfare
- Article by Pandve HT, Pandve TK on Primary healthcare system in India: Evolution and challenges
- Task Force on the roll out of Comprehensive Primary Health Care by MoHFW
- Operational guidelines on AYUSHMAN BHARAT- Comprehensive Primary Health Care through Health and Wellness
- Report by World Health Organization on India’s Primary Health Care