Revisiting primary care

October 15, 2018 0 By CH Unnikrishnan

Muralidharan Nair

The Alma Ata declaration of 1978, one of the most significant milestones in the field of public health, identified effective primary care as the very bedrock of a health system that aims for universal healthcare. The declaration defined primary health care as follows: “Primary health
care is essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.”

While there cannot be a debate on the wisdom behind the tenets of the declaration, it is evident from the state of healthcare the world over — developed and developing included — that the spirit of the declaration was not pursued. Instead, a hospital-centric model gained prominence, resulting in a universal challenge of a growing disease burden, a widening gap in access to care and the unsustainable cost of healthcare. However, there has been a call from the WHO in recent times to revisit the declaration and make it a reference point while designing the health systems of the future.

The state of primary health care in India, particularly in rural areas, where 70 percent of our population lives, is pathetic, as evidenced by the statistics below.

In such a scenario, it is very welcome to see the emphasis placed on primary care through 1.5 lakhs HWC (health and wellness centre) as a critical element of Ayushman Bharat, the incumbent government’s
flagship programme for reforming Indian healthcare. However, the success of
this endeavour will depend on the
effective transformation of point-of-care capabilities:

Investment: While 1.5 lakh HWCs is an adequate number for the effective coverage of population, there is no clarity on the timeline by which these will become operational, and also on the investment needed. One estimate available on the government website puts an amount of Rs 10 lakhs and Rs 7 lakhs as one-time and recurring expenditure for enhancing an SC to HWC, which translates to approximately 15,000 cr and 10,000 cr of one time and recurring expenditure. Where is the provision for this amount, as the current provisions being discussed are not enough even for the hospital care part of NHPS?

Training: The effective manning of this mega initiative will need innovative thinking to increase the supply of required human resource and the government has rightly planned to upskill nurses and Ayurveda doctors to man the SCs. With the expansion of focus to include mental health,
non-communicable diseases and rehabilitative care and to leverage technology, even the traditional clinical staff at the PHC level will need substantial upgradation of their skills. Hence, it is imperative that effective resourcing on such a large scale will necessitate massive training capability for creating and sustaining the operations. It will be necessary to not delegate this critical function to the states. Instead, it should be tightly controlled by a central governing body for training and certification to ensure consistent quality.

Technology: Effective use of technology for both enhancing point-of-care capabilities and bridging access to specialist advice when needed through telehealth applications will be critical.

Use of artificial intelligence (AI) based applications to aid the primary caregiver
can democratise clinical knowledge (applications for such use are being tested in the UK and other countries) and  revolutionise the effectiveness of care at the last mile.

Culture of cost containment: We have a very large underprivileged population and the budgets will never be enough. Hence, being efficient will be a moral need. This will necessitate laser-like focus on cost containment, complete with a dedicated organisation and a holistic approach, including infrastructure design, process flow, choice of formulary (e.g.: standardise centrally, maximise use of quality generics), choice of technology (e.g.: maximise frugal technology in diagnostics), contracting
(e.g.: maximise central purchases for leveraging the economies of scale) productivity norms, a performance criteria underpinned by a robust measurement and a reporting framework to facilitate timely and effective action

Effective supply chain: Public health facilities have been notorious for unavailability of medicines and related provisions. which can seriously hamper the outcome expectation from primary care. Hence it is imperative to have an agile supply chain management to ensure near 100 percent availability even while optimising the burden of inventories..


The author has long-standing association with
EY India but the views are strictly personal.