The World Health Organization’s (WHO) Alma Ata conference defined the concept of Primary Healthcare (PHC) in 1978. It formed the basis of ‘Health for All’ by 2000 AD. However, competing priorities and differential interpretation by the Member States have seen varying levels of implementation and outcomes. Political, demographic, economic, social and other factors influence the understanding that a country derives from the concept and expresses through its PHC policies. From ambulatory or first-contact personal health care services, priority health interventions for low-income populations, to an essential condition of human development, the concept of PHC has been interpreted differently for different economies. Forty years down the road, WHO has rekindled its approach PHC with a Universal Health Coverage (UHC) led ‘Asthana declaration’. It reiterated the commitment that, “….A primary health care (PHC) approach is the most effective way to sustain-ably solve today’s health and health system challenges……”
Primary healthcare through the lens of Universal Health Coverage
The concept of universal health coverage (UHC) was first touched upon by the Sickness Insurance Law, a national social health insurance policy, in 1883 Germany. Over the next few decades, the concept evolved in many countries and was implemented in many forms. In the recent years, global bodies such as the WHO and the World Bank have adopted the concept, which found its place in United Nations’ Millennium Development Goals (MDG)and Sustainable Development Goals (SDGs).
Over 50% of the world population lack full coverage for essential health services and 12% spend over 10% of their household income on medical care. Given the context, UHC aims to provide a range of essential medical care services, focusing on preventive, curative and promotive health, that are accessible, affordable and financial protection for all.
However, contrary to the widespread perception, UHC does not mean free medical care for all possible health interventions. It is, however, inclusive of legislation and governance at the highest level, supported by health financing, skilled and qualified human resource, medical, diagnostic and pharmaceutical care, health innovation and technologies, and quality assurance mechanisms.
Essential to the UHC is PHC which is the first step towards ensuring health and well-being for all.PHC remains a proven, equitable, efficient, and effective strategy to deliver the universal fundamental rights of holistic for everyone without stigma and discrimination.
Primary Healthcare in the Indian Setting
Adapting to the evolved understanding of PHC, the Health and Wellness Centres (HWCs)under the ambit of ‘Ayushman Bharat’yojna are providing services directed towards the achievement of holistic health.
Along with the traditional PHC services, the HWCsinclude non-communicable diseases management; ophthalmic and ENT care, geriatric care, emergency medical services for burns and trauma, and mental health care.
Proper implementation and robust PHC services will take India closer to achieve health-related SDGs. On one hand, the comprehensive PHC system will reduce dependency on secondary and tertiary care, reduce country’s disease burden, and reduce expenditure on countering diseases; on the other hand, it will increase job opportunities, the better overall health of the nation, and contribute to economic growth. Most significantly, while providing equal access to quality healthcare across strata of society, the system will prevent people from plunging into poverty due to out-of-pocket expenses.
To achieve the PHC objectives
While the government decision of transforming PHC centres into HWCs, followed by a National Health Protection Scheme at the secondary and tertiary level, is a step in the right direction, the transformation in the health scenario will require considerable administrative willingness and effort.
Over 68% of people are based in rural areas that face acute shortage of healthcare facilities. Healthcare workforce is far from being adequate, with 1:921 doctor-patient ratio while the country is falling short of an estimated 1.94 million nurses. In terms of facilities, India has around 0.9 beds per thousand people. There are around 25,650 PHC centres across India, with 61% of them having only one doctor each and around 7.6% PHCs having none.
In this scenario, it is important that adequate steps be taken so that the HWCs do not meet the same fate as that of the PHC centres. The fundamental principles of health system strengthening are being addressed to make this a reality. There are six pillars of health systems strengthening needed to build a robust healthcare system.
• Health governance: Investing in health governance is to ensure that a transparent and accountable system is developed, which has multiple stakeholder participation for stronger health advocacy at various regional and community levels.
• Health information is the creation of evidence-based decision-making culture, furthered by various improved approaches and tools, and which ultimately support the strategic and incremental improvement of integrated health information systems. Demographic health surveys, civil registrations and vital statistics, and district health information systems are some of the tools used.
• Health finance. The institution of preferential public financing, increasing of public and private resources for shared goals, and incentivising private sector investment in health via philanthropy or shared value creation of public-private partnerships are some of the ways through which a robust health financing structure can be built.
• A robust service delivery mechanism includes setting up of quality coordinated delivery of essential and evidence-based health services and developing and implementing cost-effective essential health services.
• Healthcare workforce. The creation of a strong human resource is essential for strengthening the health system. Conceiving and implementing effective models of imparting health education and ensuring skill training competence are important steps in the building of a strong health workforce.
• Supply chain strengthening is crucial for health systems as it ensures continuous delivery of quality health commodities and products, such as medicines, equipment, etc. The tech-enabled logistic information management system is playing a key role efficient and smooth services at primary, secondary and tertiary care level.
Imbibing these essential elements of health system strengthening, the 21st-century PHC system in India aims to provide 12 healthcare services as a part of its comprehensive care plan at the primary level. The services include pregnancy and childbirth care; neonatal and infant care; childhood and adolescent care; family planning and other reproductive care; management of communicable diseases under national health programs; management of common communicable diseases; screening and management of non-communicable diseases; screening and basic management of mental health ailments; ophthalmic and ENT care; basic oral care; geriatric and palliative care services; and emergency medical services. The advancement in technology and innovation such as Wireless technology, IT platforms, electronic health record linkages, simple point-of-care diagnostic devices are enabling the HWCs to establish an algorithm and technology-enabled system, thereby ensuring service delivery and continuum of care.
Over 50% of the world population lack full coverage for essential health services and 12% spend over 10% of their household income on medical care. Given the context, UHC aims to provide a range of essential medical care services, focusing on preventive, curative and promotive health, that are accessible, affordable and financial protection for all.
However, contrary to the widespread perception, UHC does not mean free medical care for all possible health interventions. It is, however, inclusive of legislation and governance at the highest level, supported by health financing, skilled and qualified human resource, medical, diagnostic and pharmaceutical care, health innovation and technologies, and quality assurance mechanisms.
Essential to the UHC is PHC which is the first step towards ensuring health and well-being for all.PHC remains a proven, equitable, efficient, and effective strategy to deliver the universal fundamental rights of holistic for everyone without stigma and discrimination.
Primary Healthcare in the Indian Setting
Adapting to the evolved understanding of PHC, the Health and Wellness Centres (HWCs)under the ambit of ‘Ayushman Bharat’yojna are providing services directed towards the achievement of holistic health.
Along with the traditional PHC services, the HWCsinclude non-communicable diseases management; ophthalmic and ENT care, geriatric care, emergency medical services for burns and trauma, and mental health care.
Proper implementation and robust PHC services will take India closer to achieve health-related SDGs. On one hand, the comprehensive PHC system will reduce dependency on secondary and tertiary care, reduce country’s disease burden, and reduce expenditure on countering diseases; on the other hand, it will increase job opportunities, the better overall health of the nation, and contribute to economic growth. Most significantly, while providing equal access to quality healthcare across strata of society, the system will prevent people from plunging into poverty due to out-of-pocket expenses.
To achieve the PHC objectives
While the government decision of transforming PHC centres into HWCs, followed by a National Health Protection Scheme at the secondary and tertiary level, is a step in the right direction, the transformation in the health scenario will require considerable administrative willingness and effort.
Over 68% of people are based in rural areas that face acute shortage of healthcare facilities. Healthcare workforce is far from being adequate, with 1:921 doctor-patient ratio while the country is falling short of an estimated 1.94 million nurses. In terms of facilities, India has around 0.9 beds per thousand people. There are around 25,650 PHC centres across India, with 61% of them having only one doctor each and around 7.6% PHCs having none.
In this scenario, it is important that adequate steps be taken so that the HWCs do not meet the same fate as that of the PHC centres. The fundamental principles of health system strengthening are being addressed to make this a reality. There are six pillars of health systems strengthening needed to build a robust healthcare system.
• Health governance: Investing in health governance is to ensure that a transparent and accountable system is developed, which has multiple stakeholder participation for stronger health advocacy at various regional and community levels.
• Health information is the creation of evidence-based decision-making culture, furthered by various improved approaches and tools, and which ultimately support the strategic and incremental improvement of integrated health information systems. Demographic health surveys, civil registrations and vital statistics, and district health information systems are some of the tools used.
• Health finance. The institution of preferential public financing, increasing of public and private resources for shared goals, and incentivising private sector investment in health via philanthropy or shared value creation of public-private partnerships are some of the ways through which a robust health financing structure can be built.
• A robust service delivery mechanism includes setting up of quality coordinated delivery of essential and evidence-based health services and developing and implementing cost-effective essential health services.
• Healthcare workforce. The creation of a strong human resource is essential for strengthening the health system. Conceiving and implementing effective models of imparting health education and ensuring skill training competence are important steps in the building of a strong health workforce.
• Supply chain strengthening is crucial for health systems as it ensures continuous delivery of quality health commodities and products, such as medicines, equipment, etc. The tech-enabled logistic information management system is playing a key role efficient and smooth services at primary, secondary and tertiary care level.
Imbibing these essential elements of health system strengthening, the 21st-century PHC system in India aims to provide 12 healthcare services as a part of its comprehensive care plan at the primary level. The services include pregnancy and childbirth care; neonatal and infant care; childhood and adolescent care; family planning and other reproductive care; management of communicable diseases under national health programs; management of common communicable diseases; screening and management of non-communicable diseases; screening and basic management of mental health ailments; ophthalmic and ENT care; basic oral care; geriatric and palliative care services; and emergency medical services. The advancement in technology and innovation such as Wireless technology, IT platforms, electronic health record linkages, simple point-of-care diagnostic devices are enabling the HWCs to establish an algorithm and technology-enabled system, thereby ensuring service delivery and continuum of care.
(Dr Dipanjan Sujit Roy is Chief Executive Officer, Wadhwani Initiative of Sustainable Healthcare)