Re-imagining designs of primary healthcare for the future

Primary health care is rooted in a commitment to social justice and equity and in the recognition of the fundamental right to the highest attainable standard of health

-World Health Organisation

October 2018 marked 40 years of the Alma Ata Declaration that brought together global leaders, public health practitioners towards a collective commitment to delivering high-quality healthcare for all, with the underlying values of social justice, equity and recognising the need to address social determinants of health.

The foundation for India’s primary healthcare was laid back in 1946 , with the recommendations of Bhore Committee which led to the structuring of the health system at two levels of care- primary and secondary. Comprehensiveness in services at the primary level of care (preventive , promotive and primary curative) through the network of Primary Health Centres was based on the premise that early detection and timely treatment helped reduce morbidity and severity of diseases. Building on these principles, the National Health Policy of 2016 adopted the two-pronged strategy – universal access to care through a national health insurance scheme and transforming the foremost points of contact-the subcentres to improve access and quality of primary healthcare.

However, with changing times, the evolution of technology, changing demographic distribution new challenges and opportunities call for a re-imagination of the design of primary healthcare attuned to the present and innovative enough to address the emerging needs of the future. Changing epidemiology with double disease burden (prevalence of both communicable and non-communicable illnesses), urbanisation leading to a greater rural-urban divide, high levels of migration pose challenge to the existing healthcare system. This, along with a fragmented system of care with verticalised approach, poorer reach in the community and services lacking in depth and quality are reasons for which out-of-pocket expenses on healthcare still remains more or less static.

Re-imagining designs for future require first an acknowledgement of the key attributes of primary health care:

  • care provided closer to the community, with close engagement with the community
  • accessible financially, geographically and across different illnesses
  • low-cost high-quality comprehensive care which includes preventive, promotive, screening and early detection and curative services
  • person-focused approach to care
  • well integrated with advanced levels of care and appropriate technology
  • universalistic as well as designing health solutions based on the needs of the community in the catchment, including the marginalised populations
  • encompassing a holistic, proactive, continuum of care that focuses on health and well-being

In the ambit of future designs, building a strong multi-disciplinary primary healthcare team is essential. This involves a paradigm shift from the standalone physician to skilling cadres of providers like Nurse Practitioners, community health workers, and Family Physicians. The role of Care Coordinator in planning and integrating various primary care functions, the inclusion of other allied health professionals for palliative and rehabilitative care will be critical to the delivery of a comprehensive package of services effectively. Appropriate and disruptive technology is seen as a key enabler in the process of healthcare delivery.

Quality assurance is integral to healthcare delivery and in India’s three-tiered healthcare structure quality of care applies across primary, secondary and tertiary levels. Delivery of high-quality primary healthcare services will involve standardisation of protocols, processes, robust management information systems, a continued system of quality audits, assured availability of drugs and supplies. Ways to ensure adherence to patient rights, redressal mechanisms and a decentralised form of governance will contribute to the several dimensions of quality care. A comprehensive curriculum of training and skill-building that involves both clinical care and community immersion will build a strong primary healthcare cadre proficient in clinical skills, sensitive to the needs of the community as well as adept in management and coordination skills.

Community participation has been seen as a fundamental element of primary care. The role of primary healthcare has been envisioned to take up a proactive role in initiating close engagement with communities, addressing socio-cultural barriers to health and providing care while located within the community.

Financial investment in healthcare has a major role in reducing out-of-pocket expenditures and ensuring equity. India’s current spending on primary healthcare is Rs 1700 per capita of which one-third is public and rest, private. Designing a primary care package thus would require assessing the cost-benefits of the services involved, situation analysis, the impact it can have on equity as well as making sense of the political climate. In the current context, financing needs to boost up through higher budgetary allocations by the Government, innovative funding mechanisms such as cooperative based financing, and increased CSR investments. Scope for incentivising patients for increasing uptake, cross-subsidising will be important frontiers to explore for future designs.

The definition that underlines the key elements of the primary healthcare discussed above is :

Primary health care simply put is a community-based health care system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides for all but very uncommon or unusual conditions, and coordinates or integrates care provided elsewhere by others.
(Starfield 1998)

The above discussions have been extracted from the Report on Future Designs of Primary HealthCare. Health Systems Transformation Platform (HSTP) in partnership with Basic HealthCare Services (BHS) and PGIMER , Chandigarh convened a Design Thinking Workshops to brainstorm on the vision and agenda for designing and implementing innovative models of healthcare across different parts of India. In December 2018, 40 experts from academia, public health, Government , Civil Society, finance and technology participated in the first two-day workshop held in New Delhi.

The Report of the Workshop was jointly prepared by BHS and HSTP and published in April 2019. Here is a link to the full report:

By Manisha Dutta, Program Executive, Basic HealthCare Services