Delivering comprehensive primary healthcare
Rather than such a static come-to-me model, health services need to reach households. Our frontline workers are capable of doing that with adequate training and support.
Ayushman Bharat has become the integrative platform for most of the health programmes in the country. When launched in 2018, it had two major components—Comprehensive Primary Health Care (CPHC) through Health And Wellness Centres (HWCs) and healthcare financing for hospitalised care of economically vulnerable segments of the population via Pradhan Mantri Jan Arogya Yojana (PMJAY).
In 2021, two more missions were launched, under the umbrella of Ayushman Bharat, to expand health services and enhance the quality of care. These are the Health Infrastructure Mission and the Digital Health Mission. They augment and enable the two service delivery arms of Ayushman Bharat and contribute to strengthening of the overall architecture and performance of the health system.
The first Health And Wellness Centre (HWC) was launched by the prime minister at Jangla, Bijapur in Chhattisgarh on 14 April 2018. While primary health centres (PHCs) and sub-centres were a longstanding feature of India’s rural health services, the HWC proclaimed a new agenda centred around CPHC. This was a shift from selective primary care, which was the track on which the National Rural Health Mission (NRHM) travelled before it graduated to the National Health Mission (NHM) by adding an urban component.
CPHC, to be delivered through upgraded sub-centres and PHCs, is intended to cover a wide array of health services, addressing a majority of the basic health needs of the population. Earlier, the NRHM was geared towards delivering services related to maternal and child health besides a few major infectious diseases. This menu was aligned to the limited health agenda of the Millennium Development Goals of 2000. Only about 15% of the many health needs of primary care were met through these focused but restricted set of services.
By adding services related to a wide range of non-communicable and communicable diseases, mental health, addictive disorders, health promotion, yoga and rehabilitation, CPHC aims to expand the ambit of care. Essential drugs will be provided and basic diagnostic tests would be performed at HWCs. Tele-health services will link them to specialist evaluation and guidance.
The ethos of primary healthcare is to provide comprehensive, continuous and connected care for a wide variety of common health conditions, while promoting health and preventing disease. The mandate encompasses early detection of health disorders and their risk factors, prompt initiation of effective care at home or near home, connection to specialist care when needed by tele-health or referral to secondary or tertiary care facilities, while ensuring continuity of care for the majority who need only primary care or return from advanced care. A wide range of promotive and preventive services, from immunisation, health and nutrition literacy to tobacco and alcohol control need to be a prominent part of primary care.
Such a description should not lead to a misconception, as often happens with health system managers, that primary care is mainly or only facility-based, which requires people to approach them for healthcare. Rather than such a static come-to-me model, health services need to reach households. Our frontline workers are capable of doing that, with adequate training and support from easy-to-handle health technologies. Apart from antenatal services and child care, even care of chronic conditions like hypertension and diabetes can be effectively delivered by them. Point-of-care diagnostics can also enable many tests to be performed at home.
Healthcare must also connect with communities. If services are designed and delivered with active community engagement, they have a better chance of success. The community also enables alignment of multi-sectoral actions to health goals by promoting coherence and convergence. Water, sanitation, road safety and pollution control are obvious examples. Disease surveillance too is efficient in providing early alerts and effective in containment if communities are engaged. Flow of primary care funds to rural and urban local bodies, as recommended by the Fifteenth Finance Commission, provides them the opportunity and resources to drive health-friendly development.
CPHC needs to overcome the segmented-by-age and fragmented-by-disease approach of selective primary care advocated and driven by donors. To provide a life-course approach that addresses varying health priorities that surface at different ages, primary care needs to look at the family as a unit and home as a key locale of care. That will also promote a combination of self care and family-assisted care. ‘Healthy Homes In Healthy Communities’ must become the guiding vision of CPHC.
This cannot happen without adequate investments in infrastructure, human resources, drugs and supplies, appropriate technologies and efficient governance. We need more technology-enabled frontline health workers, doctors trained in family medicine and dedicated public health management cadre to deliver the agenda of primary care. As we move towards realising the vision of establishing 1,50,000 HWCs, we must ensure that each of them functions to their full potential. For now, we can draw satisfaction from the fact that primary healthcare has finally emerged from the shadows of neglect to the centre stage of health policy.
Dr K Srinath Reddy
Cardiologist, epidemiologist and President, Public Health Foundation of India (PHFI)