Since Independence, India has been striving to establish a comprehensive primary healthcare care system. The Bhore Committee Report of 1946, the Kartar Singh Committee Report of 1973, the National Rural Health Mission (NRHM) of 2005 and the Ayushman Bharat Mission of 2019 are significant landmarks in this endeavour. The system today comprises a multi-tiered structure with a 30-bed community health centre operated by four specialists at the block-level and a community worker at the village-level. The services cover 12 diseases/needs.
The NRHM was a game changer. Backed by political imagination and a three-fold increase in budget, the mission set standards for physical infrastructure, human resources and service delivery — the Indian Public Health Standards (IPHS). The focused approach resulted in substantial gains — institutional deliveries went up from 41 per cent in 2005 to 89 per cent in 2021, the maternal mortality ratio went down from 407 per one lakh women in 2,000 to 113 per one lakh women in 2021 and the infant mortality ratio reduced from 58/1,000 live births in 2005 to about 28/1,000 live births in 2021. With increased availability of drugs, diagnostics and doctors, the healthcare system’s footfall has registered an impressive improvement in states like Bihar and UP. The embedding of a million foot soldiers in the community is a major achievement.
Despite these efforts, however, less than 10 per cent of the facilities match up to the IPHS. One reason for the deficit is that public spending on healthcare is barely 1.1 per cent of the GDP. The other reason is the wavering political support for primary care. As a result, the primary healthcare system continues to be plagued with gaps and deficiencies and the current facilities serve two to ten times the population they are designed to cater to.
The Covid pandemic once again highlighted the need for an effective primary healthcare system. The overcrowding of hospitals with anxious patients, the utter confusion and the stress on families, desperate for credible advice, brought to the fore the need for family doctors and a resilient primary health system. It is not as if policymakers have been unaware of the need for close-to-home facilities to address everyday healthcare needs. The UK’s GP (general practitioners) system has been a part of the public health discourse in the country for nearly a decade. The barrier has, however, been the lack of understanding of how to transplant this system to India, given the wide differences in the history, culture and conditions of the two countries.
Kerala seems to have quietly begun the reform process. In 2014, the state set up a pilot in three PHCs under guidance from and help of the Imperial College, London along with support from DFID. The reconstruction process started with the acceptance of the basic but often-ignored fact — the facility design must cater to community needs. This meant assessing the demographic and epidemiological ground realities and acknowledging that the 70-year-old PHC structure did not have the institutional capacity to manage chronic diseases — the deficit had to be plugged urgently because most such diseases last several years and treating them requires a holistic approach.
Renaming the facilities as family health centres underlined the centrality of the family in the endeavour. A series of coordinated interventions were made — changing timings, redesigning the centres and equipping them with patient and people-friendly facilities, providing intensive training to the staff to undertake new functions and responsibilities, improving diagnostic facilities, computerising data to make processes paper less, triaging patients for maximum utilisation of doctors time, referral of patients to higher levels of care and ensuring post hospitalisation follow-ups. The PHCs in Kerala provide a wide range of drugs and medical services, including nebuliser treatment for asthma patients. It’s the only state where mobile teams provide palliative care at home. Almost 550 FHCs are functioning in the state.
This comprehensive approach has been enabled by a tripartite partnership between the state’s health department, women’s collectives and community-level bodies. While the local bodies provide the funding, the volunteer base comes from the collectives and the health department delivers the services. Kerala appears to be the only state to revamp its primary healthcare system along the foundational principles of comprehensive primary care — a community-anchored delivery system, a continuum of care, and patient-centred, protocol-driven, evidence-based treatment.
The state’s task is, however, not over. Reform needs deepening, and the accountability framework needs to be strengthened. In other words, the doctors, paramedics and frontline workers must be held responsible for the health and well-being of every member of the families that are under their charge, and this responsibility has to be backed by financial and non financial incentives. Such interventions can be particularly useful in reducing the insulin dependence of a diabetic through sound case management and effective counselling on lifestyle changes — proper medications, diet, exercise, and yoga. A proactive primary healthcare system such as this can help early in the diagnosis, reduce hospitalisations and bring down severe morbidity and mortality. Achieving these goals is of immense importance in cash-strapped and low-resource settings, especially because the cost of healthcare escalates threefold, the higher one goes up the care ladder.
But then what Kerala is attempting is not what Bihar, UP or Assam should. Interstate differentials in morbidity patterns are wide and health systems need to be tweaked according to a state’s disease burden. National policy, therefore, needs to be nimble and allow for differential strategies — a single system may not be apt for the entire country. The sooner the Centre accepts the principles of flexibility, decentralisation and provides the space for innovation to states and districts to plan, design and implement primary care in accordance with local needs, the better it would be — the Centre’s role should be limited to measuring outcomes.
The question is not only about increasing financial resources but resetting the approach and changing the design. We have spent 75 years struggling to have a sound primary healthcare system, one that prevents illness as well as heals. It’s time to speed up the effort.
The writer is former Union health secretary
