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 Table of Contents  
REVIEW ARTICLE
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 125-128

Primary healthcare system in India: Evolution and challenges


1 Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, India
2 Health Advice Call Center, Aundh, Pune, Maharashtra, India

Date of Web Publication20-Mar-2014

Correspondence Address:
Harshal Tukaram Pandve
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, Maharshtra - 411 041
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9019.129126

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  Abstract 

Primary healthcare is a vital strategy which remains the backbone of health service delivery. Primary healthcare is the day-to-day care needed to protect, maintain, or restore our health. For most people, it is both their first point of contact with the healthcare system and their most frequently used health service. In India concept of primary healthcare was laid down by the recommendations of Bhore Committee (1946). In last 6 decades of independence, we have seen much improvement in primary healthcare services, infrastructure, and related healthcare indices of the country. Still many challenges are ahead to achieve health for all. There is a need to review primary healthcare in the country to know our strengths and weaknesses to face the challenges in the future. This review article discusses the evolution of primary healthcare system in India over period of time. It also focuses on the challenge for primary healthcare system in current scenario and in future. A search strategy involved a detailed literature review on the subject of primary healthcare system in India. Indexed and non-indexed journals, websites of important organizations, and national programs in the field were identified and searched for key words. The most relevant publications were reviewed in detail and included in the present review.

Keywords: Challenges, evolution, India, primary healthcare


How to cite this article:
Pandve HT, Pandve TK. Primary healthcare system in India: Evolution and challenges. Int J Health Syst Disaster Manage 2013;1:125-8

How to cite this URL:
Pandve HT, Pandve TK. Primary healthcare system in India: Evolution and challenges. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2019 Jan 18];1:125-8. Available from: http://www.ijhsdm.org/text.asp?2013/1/3/125/129126


  Introduction Top


The primary healthcare approach was described as "essential 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". [1] The Alma-Ata Declaration also emphasizes that everyone should have access to primary healthcare, and everyone should be involved in it. The primary healthcare approach encompasses the following key components: Equity, community involvement/participation, intersectorality, appropriateness of technology and affordable costs. Primary healthcare as defined above will do much to address many of the prerequisites for health indicated earlier. [2]

For this review article, search strategy involved a detailed literature review on the subject of primary healthcare in India. Indexed and non-indexed journals, websites of important organizations, and national programs in the field were identified and searched for key words like primary healthcare, India, Challenges. Search engine included Google and PubMed. The most relevant 20 publications were reviewed in details and included in the article.


  Evolution of Primary Healthcare System in India Top


Primary healthcare is a vital strategy that remains the backbone of health service delivery. India was one of the first countries to recognize the merits of primary healthcare approach. Long before the Declaration of Alma-Ata, India adopted a primary healthcare model based on the principle that inability to pay should not prevent people from accessing health services. Derived from the recommendations of the Health Survey and Development Committee Report 1946, under the chairmanship of Sir Joseph Bhore, the Indian Government resolved to concentrate services on rural people. This committee report laid emphasis on social orientation of medical practice and high level of public participation. With beginning of health planning in India and first five year plan formulation (1951-1955) Community Development Programme was launched in 1952. It was envisaged as a multipurpose program covering health and sanitation through establishment of primary health centers (PHCs) and subcenters. By the close of second five year plan (1956-1961) Health Survey and Planning Committee (Mudaliar Committee) was appointed by Government of India to review the progress made in health sector after submission of Bhore Committee report. The major recommendations of this committee report was to limit the population served by the PHCs with the improvement in the quality of the services provided and provision of one basic health worker per 10,000 population. The Jungalwalla Committee in 1967 gave importance to integration of health services. The committee recommended the integration from the highest to lowest level in services, organization, and personnel. The Kartar Singh Committee on multipurpose workers in 1973 laid down the norms about health workers. Shrivastav Committee (1975) suggested creation of bands of para-professionals and semi-professional worker from within the community like school teachers and post masters. It also recommended the development of referral complex by establishing linkage between PHCs and high level referral and service centers. Rural Health Scheme was launched in 1977, wherein training of community health, reorientation training of multipurpose workers, and linking medical colleges to rural health was initiated. Also to initiate community participation, the community health volunteer "Village Health Guide" scheme was launched. The Alma-Ata Declaration of 1978 launched the concept of health for all by year 2000. The declaration advocated the provision of first contact services and basic medical care within the framework of an integrated health services. Several critical efforts outlined Government of India's commitment to provide health for all of its citizens after Alma-Ata declaration. The report of study group on "Health for All: An Alternative Strategy" commissioned by Indian Council for Social Science Research (ICSSR) and Indian Council for Medical Research (ICMR) (1980) argued that most of health problems of a majority of India's population were amenable to being solved at the primary healthcare level through community participation and ownership. Alma-Ata declaration led to formulation of India's first National Health Policy in 1983. The major goal of policy was to provide universal, comprehensive primary health services. Nearly 20 years after the first policy, the second National Health Policy was presented in 2002. The National Health Policy, 2002 set out a new framework to achieve public health goals in socioeconomic circumstances currently prevailing in the country. It sets out an increased sectoral share of allocation out of total health spending to primary healthcare. [3] Recognizing the importance of health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has launched the National Rural Health Mission in 2005 to carry out necessary architectural correction in the basic healthcare delivery system. The goal of the mission is to improve the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women, and children. [4]


  Challenges for Primary Healthcare System in India Top


Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. In India, communicable diseases, maternal, perinatal, and nutritional deficiencies continue to be important causes of deaths noncommunicable diseases like diabetes, cardiovascular diseases, respiratory disorders, cancers, and injuries are showing the rising trends. Mental health disorders are also on the rise also taking a substantial toll of human lives. The health issues related to elderly population are common due to increase in life expectancy. India has been witnessing rapid urbanization particularly in recent decades. Currently one-fourth of the urban population lives in slums with severely compromised health and sanitary conditions. While the primary healthcare system is struggling to provide services, there is an emerging need for addressing above mentioned issues. This presents huge challenge to the current primary healthcare system in India. [5],[6] Within the next few decades, we will see an extraordinary increase in the number of older people worldwide. The public health benefit of preventive medicine in old age comes from the compression of the time spent in dependency to a minimum. The rising morbidities clearly showed that a regular, complete health checkup of the elderly should be embedded in the essential elements of the primary healthcare. [7] Patient satisfaction represents a key marker for the quality of healthcare delivery and this internationally accepted factor needs to be studied repeatedly for smooth functioning of the healthcare systems. [8],[9],[10],[11] A better appreciation of the factors pertaining to client satisfaction would result in implementation of custom made programs according to the requirements of the patients, as perceived by patients and service providers. [12] It has been observed that there is poor level of client satisfaction in rural as well as urban areas of India regarding primary healthcare services. Client satisfaction is an important measure of the quality of healthcare and needs to be addressed in order to improve the utilization of primary healthcare services. Patients often complain of rude and abrupt health workers that discriminate against women and minorities from scheduled castes or tribes. [13],[14],[15]

The current primary healthcare infrastructure and manpower is also deficient. According to Rural Health Survey (RHS) 2011, as on March 2011 there are 148,124 subcenters; 23,887 PHCs; and 4,809 community health centers (CHCs) functioning in India. The norms set for the population coverage for subcenter, PHC, and CHC for plane areas are 5,000; 30,000; and 120,000; respectively. As per RHS, 2011 the average population covered by a subcenter, PHC, and CHC was 5,624; 34,876; and 173,235; respectively. As on March, 2011 the overall shortfall in the posts of health worker (female (F))/auxiliary nurse midwife was 3.8% of the total requirement. For allopathic doctors at PHCs, there was a shortfall of 12.0% of the total requirement for existing infrastructure as compared to manpower in position. Similarly, in case of health worker (male (M)), there was a shortfall of 64.7% of the requirement. In case of health assistant (female)/lady health visitor, the shortfall was 38% and that of health assistant (male) was 43.3%. For allopathic doctors at PHC, there was a shortfall of 12.0% of the total requirement. As compared to requirement for existing CHC infrastructure, there was a shortfall of 75% of surgeons, 65.9% of obstetricians and gynecologists, 80.1% of physicians, and 74.4% of pediatricians. Overall, there was a shortfall of 63.9% specialists at the CHCs as compared to the requirement for existing CHCs. [16]

As per 2011 census, India's population is more than 121 crores. 83.3 crores (68.84%) of Indians live in rural areas. [17] Considering the population norms for PHC of 30,000 in plane areas (here the population norms for PHC of 20,000 for tribal and hilly areas is not considered), India requires more than 27,700 PHCs. So when compared with RHS, 2011; India requires 3,800 more PHCs. There is urgent need to address inadequate infrastructure as well as manpower for better service and delivery of primary healthcare. Only after addressing these issues we can think of applying Indian Public Health Standards to all healthcare infrastructures.

The current primary healthcare structure is extremely rigid, making it unable to respond effectively to local realities and needs. The lack of resources, which is acute in some states, is certainly a contributing factor to the poor performance of the primary healthcare system. [15] There is a need to explore and understand the reasons that prompt people to visit health facilities and the reasons driving them away from free government care. Ubiquitous absenteeism, low client-provider interaction, poor referral systems, and a low perceived quality of care could emerge as possible reasons for this situation. [18] Large diversity in India calls for local adaptation of the basic healthcare package and its delivery mechanism. The question confronting health systems in India is how best to reform, revitalize, and resource primary health systems to deliver different levels of service aligned to local realities, ensuring universal coverage, equitable access, efficiency and effectiveness, through an empowered cadre of health personnel. To encourage accountability, access should be monitored at district level by an independent agency. [5] There is growing need of research in improving the service delivery of primary healthcare. Qualitative research into this area could yield lessons for the delivery of future services. Research into factors influencing service utilization could lead us to developing a public health marketing strategy for care access. A conjoint effort by the state and the institutes can thus be used to reinvent primary healthcare and bring it to the forefront. Several opportunities can be explored within the facilitating atmosphere of National Rural Health Mission (NRHM). [19] Thus, it is evident that the success of health systems exists in tapping the existing potential and making appropriate structural changes. The role of primary care should not be defined in isolation but in relation to the constituents of the health system. [15]

The Millennium Development Goals (MDGs) which include eight goals were framed to address the world's major development challenges with health and its related areas as the prime focus. In India, considerable progress has been made in the field of basic universal education, gender equality in education, and global economic growth. However, there is slow progress in the improvement of health indicators related to mortality, morbidity, and various environmental factors contributing to poor health conditions. As rightly mentioned by Nath, even though the government has implemented a wide array of programs, policies, and various schemes to combat these health challenges, further intensification of efforts and redesigning of outreach strategies is needed to give momentum to the progress toward achievement of the MDGs. [20]


  Conclusion Top


India's progress towards achieving MDGs is slow and it is evident that role of primary healthcare is essential in the progress towards achieving them. To conclude, the primary healthcare system in India has evolved in due course of time but the challenges of future are needed to be addressed effectively to achieve the MDGs.

 
  References Top

1.World Health Organization. Primary Health Care-Report of the International Conference on Primary Health Care. Geneva: WHO; 1978. Available from: http://www.who.int/publications/almaata_declaration_en.pdf. [Last accessed dated on 2013 Mar 11].  Back to cited text no. 1
    
2.Health Promotion Glossary. Available from: http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf. [Last accessed dated on 2013 Mar 11].  Back to cited text no. 2
    
3.Origin and evolution of Primary health care in India. Available from: http://www.whoindia.org/LinkFiles/Health_Systems_Development_Primary_Health_Care_Origin_and_Evolution_.pdf. [Last accessed dated on 2013 Mar 11].  Back to cited text no. 3
    
4.Mission document, National Rural Health Mission. Available from: http://www.mohfw.nic.in/NRHM/Documents/Mission_Document.pdf. [Last accessed dated on 2013 Mar 11].  Back to cited text no. 4
    
5.Kumar R, Kaur M, Jha P. Universalizing access to primary health care in India. Indian J Public Health 2009;53:22-7.  Back to cited text no. 5
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6.Primary health care: Current challenges and way forward. Available from: http://www.whoindia.org/LinkFiles/Health_Systems_Development_Primary_Health_Care_Current_health_challenges_.pdf. [Last accessed dated on 2013 Mar 11].  Back to cited text no. 6
    
7.Agrawal S, Deo J, Verma AK, Kotwal A. Geriatric health: Need to make it an essential element of primary health care. Indian J Public Health 2011;55:25-9.  Back to cited text no. 7
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8.Almujali AA, Alshehy AH, Ahmed A, Ismail MF. Assessment of enablement effect of consultation on patients attending primary health centers in Qatar. Middle East J Family Med 2009;7:3-6.  Back to cited text no. 8
    
9.Ganova-Iolovska M, Kalinov K, Geraedts M. Satisfaction of inpatients with acute coronary syndromein Bulgaria. Health Qual Life Outcomes 2008;6:50.  Back to cited text no. 9
    
10.Prasanna K, Bashith M, Sucharitha S. Consumer satisfaction about hospital services: A study from the outpatient department of a private medical college hospital at Mangalore. Indian J Community Med 2009;34:156-9.  Back to cited text no. 10
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11.Mendoza Aldana J, Piechulek H, Al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ 2001;79:512-7.  Back to cited text no. 11
    
12.Iftikhar A, Sirajud D. Patients′ satisfaction from the Health care services. Availablw from: http://www.gjms.com.pk/files/Review%20Vol-8-1.pdf. [Last accessed on 2013 Mar 03].  Back to cited text no. 12
    
13.Rashmi VB. Client satisfaction in rural India for Primary Health Care - A Tool for Quality Assessment. Al Ameen J Med Sci 2010;3:109-14.  Back to cited text no. 13
    
14.Patro BK, Kumar R, Goswami A, Nongkynrih B, Pandav CS. Study Group UG. Community perception and client satisfaction about the primary health care services in an urban resettlement colony of New Delhi. Indian J Community Med 2008;33:250-4.  Back to cited text no. 14
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15.Patel N. Evaluating the role of Primary Health Centers in India. Available from: http://www.expresshealthcaremgmt.com/20050831/ruralhealthcare01.shtml. [Last accessed on 2013 Mar 03].  Back to cited text no. 15
    
16.Rural Health statistics in India 2011. Available from: http://nrhm-mis.nic.in/UI/RHS/RHS%202011/RHS%202011%20Webpage.htm [Lastaccessed on].  Back to cited text no. 16
    
17.Rural urban distribution of population, Census of India 2011 provisional population tables. Available from: http://censusindia.gov.in/2011-prov-results/paper2/data_files/india/Rural_Urban_2011.pdf. [Last accessed on 2013 Mar 03].  Back to cited text no. 17
    
18.Zodpey S. Can primary health care reinvent itself to impact health care utilization? Indian J Public Health 2010;54:55-6.  Back to cited text no. 18
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19.Carter YH, Shaw S, Macfarlane F. Primary Care Research Team Assessment: Development and evaluation. Occas Pap R Coll Gen Pract 2002;iii-vi, 1-72.  Back to cited text no. 19
    
20.Nath A. India′s progress toward achieving the millennium development goals. Indian J Community Med 2011;36:85-92.  Back to cited text no. 20
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