(Hosted during 15thWorld Rural Health Conference 2018 New Delhi)
27th April 2018, India Habitat Centre, New Delhi
There are several definitions of primary health care(1-3) but most have the following key elements:
Because of these features, primary health care helps in promoting health related behavior, preventing ill health and detecting and treating the illnesses early, closer to where families live. Any health system needs to have a balance of primary, secondary and tertiary healthcare.
However, for a health system that wishes to achieve universality and to be cost effective and equitable, primary healthcare needs priority attention and resources. By focusing on preventive and promotive health, primary healthcare reduces illness load in the community, and through early detection and treatment, the severity of illnesses. Reduced occurrence of illness and reduced severity leads to reduced costs to the system, as well as to the families. Since primary healthcare services are located closer to the communities, it encourages them to seek care early with greater comfort, and reduce disruption in their livelihoods. A strong primary healthcare also reduces the load at secondary and tertiary health services, allowing them to become more effective and efficient.
Evidence from across the world indeed shows that the countries that have a strong primary health care systems have better health outcomes, lower inequalities in these outcomes, and lower costs of care(3-6).
In India, the primary healthcare system was designed based on recommendations of the Bhore Committee (1946) just before Indian Independence. The system consists of a network of Primary Health Centers. Each primary health center covers a population of 20,000 to 30,000 and provides outreach services to the catchment population through 4-5 sub-centers, each serving a population of 3000 to 5000. Each PHC provides preventive, promotive and curative services. Each PHC is linked to a Community Health Center (CHCs), one each for 4-5 PHCs, equipped to provide secondary care.
National Rural Health Mission added two significant elements to this design: a village level volunteer to further extend the reach and depth of promotive care (ASHA); and an ambulance services that help in transporting severely ill patients to the CHC or higher levels of care.Increased investments in this Primary Health Care system between the years 2005-2015 led to significant improvements in health related behavior (e.g. % children exclusively breastfed till 6 months increased from 46% to 55%), as well as preventive interventions (such as institutional births from 39% to 79%, full immunization from 44% to 62%). There is also a clear evidence that this increase was equitable: gap between coverage of these interventions between rural and urban decreased over these years(7, 8).
However, during the same period, most families in rural as well as urban India did not come to primary health centers or community health centers when they fell ill: they either did not seek care or sought care from private (informal or formal) providers, and continued to pay a heavy price for doing so: almost 70% of all the healthcare expenditure. Even for disease of huge public health importance such as TB, absence of well-functioning PHCs led to almost an epidemic of Multi Drug Resistance(9). Also, though the coverage of preventive interventions increased (such as institutional childbirth), the quality remains poor.
Primary health care services in India are located too far from the populations they serve and provide too little services. Each PHC in India is supposed to serve a population of 20-30,000 which makes them too far for many families to reach, and for the providers to provide continued care(10). In many parts of the world, there is a functional primary health care facility at a population of 2000-3000. Primary Health care services in India also rely too heavily on the presence of doctors, despite having a shortage of doctors nationally. Since many doctors do not often live in the rural areas, the primary health centers become dysfunctional. There is also no cadre of primary care providers in the country, unlike many Western countries, where General Physicians and Nurse Clinicians are the certified primary care providers. MBBS doctors are by default the primary care providers in India with no additional training. In absence of an appropriate training, physicians and nurses fail to manage and meet the needs of the communities. In recent years, residency programs in family medicine and nurse practitioner courses have sought to address this gap, but very slowly and hesitatingly.
National Health Policy 2016 and budgetary announcements of the year 2018 take a two pronged approach for strengthening healthcare in India: improving access and quality of primary health care through strengthening 1,50,000 sub-centers (transforming them to health and wellness centers), and improving access to secondary and tertiary care through a near universal health insurance scheme. However there has been a criticism that the budgetary allocations to achieve these policy objectives are inadequate(11).
Information and insights from different sources, both within and outside India will be helpful in achieving these policy objectives. For example, for strengthening sub-centers into health and wellness centers, what skills and what human resources will be required? What technology will enable this transformation? What are the changes that would need to make in supervisory structures? What simultaneous investments will be required in primary health centers? How do we build linkages with other levels of care? And finally, what costs will be required? How do we create knowledge as we roll out these ambitious interventions?
India�s economy is growing well, rural infrastructure is improving and it has access to technology, all of which have the potential to transform health status of its populations. Different state governments such as Himachal Pradesh have set up strong primary health care systems despite access problems. Also, at the national level, primary health care systems have led to significant increase in coverage and reduction in disparities among some interventions such as institutional births and immunization coverage. These experiences can guide further course of action.
Many not-for-profit organizations that work in difficult to reach rural areas have innovated to improve access, responsiveness and quality of primary healthcare. For example to offset the shortage of physicians, some of them have worked with Primary Care Nurses, some have used technology for improved diagnostics and for tele-consultation and training, and most have partnered with communities to promote community participation. Though these models have a limited coverage, their experience, insights and evidence from the ground has substantial potential to inform the programs and policies.
Finally, there are substantial, long term experiences of several countries that have addressed the problem of delivering universal, high quality primary health care, even to the underserved populations. Among the developed world, Australia and Canada are two shining examples. Among the lesser developed world, Srilanka was able to eliminate malaria even in strife regions, that is a testimony to the strong foundation of their primary health care systems. MD GP program in Nepal is yet another example of medical education innovation towards addressing shortage of skilled work force in rural / remote areas.
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