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Fixing Sickness Care Component of Comprehensive Primary Health Care in India

Article · January 2020

DOI: 10.23880/JQHE-16000165

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 Journal of Quality in Health care & Economics
ISSN: 2642-6250
MEDWIN PUBLISHERS
Committed to Create Value for researchers

Fixing Sickness Care Component of Comprehensive Primary

Health Care in India

Suresh K*
Research Article
Public Health Consultant, India
Volume 3 Issue 3
Received Date: May 11, 2020
*Corresponding author: Suresh Kishanrao, Public Health Consultant & Visiting Professor-
Published Date: June 18, 2020
MPH, Schools of Environmental Science, Public Health and Sanitation Management, Karnataka
DOI: 10.23880/jqhe-16000165
State Rural Development and Panchayat Raj University (KSRDPRU), GADAG and Rajiv Gandhi
Institute of Public Health, Bengaluru, Karnataka .Tel: 918029571102, 919810631222; Email:
[email protected]

Abstract
With recent Coronal virus Pandemic India, hopefully public health in general and comprehensive primary health care will
come to the forefront. The focus will shift from private hospitals to government hospitals as private hospitals are too small to
handle large-scale health emergencies and care of the poor. And instead of sourcing medical devices and equipment and drugs
from abroad, everything will be sourced from India. In February 2017, Government of India promised to upgrade 150,000
existing HSCs and PHCs into Health and Wellness Centres (HWCs) that will switch from “selective” to “comprehensive primary
health care” and start providing the larger package of services in Public Sector Health.

Empowering paramedical workers for early diagnosis and dispensing pre-decided drugs began way back in 1953 for Malaria
control. The training of Multipurpose Health Workers (Male and Female) introduced capacity building for minor ailments
treatment in 1974. Later vertical interventions at community level, like Control of diarrheal diseases (1980), Acute Respiratory
infections (1990), standalone new-born care and integrated management of neonatal and childhood illnesses (IMNCI) in early
2000 were added in the job descriptions of the health workers. NHP 2017 makes it mandatory to run outpatient clinics for
6 hours every day at the HWCs, institutionalizing regular sickness care services at the community level for comprehensive
health care.

The design of HWCs and the delivery of services build on the experiences and lessons learnt from the National Health Mission,
India’s flagship programme for strengthening health systems. To address the expanded service delivery package will require
reorganization of work processes, addressing the continuum of care across facility levels; moving from episodic pregnancy and
delivery, new born and immunization services to chronic care services; instituting screening and early treatment programmes;
ensuring high-quality clinical services; using information and communications technology, focusing on health promotion and
addressing health literacy.

The announcement of HWCs received wide coverage and attention. However, promises are an integral part of Indian polity;
the challenge is implementation as witnessed being part of the health system by the author since 1968. The first Health
and Wellness Centre (HWC) under Ayushman Bharat was inaugurated by the Prime Minister at on 14/04/2018. Since then
29214 AB-HWC are reported functional as on 30.01.2020. The word functional is used for issuing government order or at
the most change of the sign board of the facility. Two years down the line there is hardly any visible change in the strategy of

Fixing Sickness Care Component of Comprehensive Primary Health Care in India J Qual Healthcare Eco
 2 Journal of Quality in Health care & Economics

providing sickness care for six hours a day as envisaged and starting of the new interventions included in service package
on the ground level. The availability of services would evolve in different states gradually, depending on three factors- a) the
availability of suitably skilled human resources at the HWC, b) the capacity at district/sub-district level to support the HWC in
the delivery of that service, and c) the ability of the state to ensure uninterrupted supply of medicines and diagnostics at the
level of HWC.

This article analyses the existing primary health care system in the country, challenges of establishing HWCs for CPHC specially
at HSC level and the way forwards.

Keywords: Comprehensive Primary Health Care; Health Sub-centre; Health and Wellness Centres; Middle Level Health
Provider; Universal Health Coverage

Abbreviations: CPHC: Comprehensive Primary Health The concept of PHC has been repeatedly reinterpreted
Care; UHC: Universal Health Coverage; HSCs: Health Sub and redefined in the years since 1978, the most recent
Centres; PHCs: Primary Health Centres; CHCs: Community being in October 2018, in Astana, Kazakhstan, when world
Health Centres; HWCs: Health Wellness Centres; MLHP: leaders met to commemorate the 40th anniversary of the
Middle Level Health Provider; NHP: National Health 1978 Declaration. This vision places people, as individuals
Policy; MOH&FW; Ministry of Health & Family Welfare; AB: and communities, as the central focus of all efforts towards
Ayushman Bharat; ASHA: Accredited Social Health Activist; PHC. People’s fundamental right to the highest attainable
AWW: Anganwadi Worker; HA(M&F): Health Assistants standard of health and well-being, and the world’s renewed
(Male & Female); MO: Medical Officer. commitment to social justice, are expressed through adequate
social protection and concerted efforts to address the needs of
Introduction those who are most disadvantaged. Comprehensive Primary
Health care (CPHC) now is considered as a whole-of-society
After the first case of Corona Virus on 31 January 2020, approach to health that aims equitably to maximize the
the pandemic has shaken the health system in India. The full level and distribution of health and well-being by focusing
effects of the pandemic are yet to be measured, but change on people’s needs and preferences (both as individuals and
is already here to see. For first time ever in the history of communities) as early as possible along the continuum
Public Health India showed that it was a whole-of-society’s of care from health promotion and disease prevention to
approach to health that aimed at equitably to maximize the treatment, rehabilitation and palliative care, and as close as
level and distribution of health and well-being focusing on feasible to people’s everyday environment [1].
people’s needs and preferences early in the pandemic and
ensuring the continuum from health promotion and disease CPHC Has Three Inter-Related and Synergistic
prevention efforts like, containment, social distancing, Components
hand wash, use of masks, cough etiquettes, toilet hygiene
to treatment, rehabilitation and lockdown, and as close as 1. Meeting people’s health needs through comprehensive
feasible to people’s everyday environment. Focus shifting promotive, protective, preventive, curative, rehabilitative,
to strengthening government health system by creating and palliative care throughout the life course, strategically
dedicated facilities, procuring ventilators, PPEs, and Rapid prioritizing key health care services aimed at individuals and
test kits and strengthening laboratory services for PCR. families through primary care and the population through
public health functions as the central elements of integrated
We are now convinced that Public health in general health services; 2. Systematically addressing the broader
and comprehensive primary health care will come to the determinants of health (including social, economic and
forefront. People must learn to live with SARC Cov-2 (Covid environmental factors, as well as individual characteristics
19) and many other viruses and pathogens. The focus will and behaviour) through evidence- informed policies and
shift from private hospitals to government hospitals as actions across all sectors; and 3. Empowering individuals,
private hospitals are too small to handle large-scale health families, and communities to optimize their health, as
emergencies and care of the poor. Instead of sourcing medical advocates for policies that promote and protect health and
devices and equipment and drugs from abroad, everything well-being, as codevelopers of health and social services,
will be sourced from India. and as self-carers and caregivers. This new approach to

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 3 Journal of Quality in Health care & Economics

Comprehensive primary health care is central to achieving like schoolteachers and post-masters. It recommended the
the SDGs and UHC. Progress will require courage and development of referral complex by establishing linkage
determination, but the time is right [1]. between PHCs and high-level referral and service centres
(First Referral Units- FRUs). Rural Health Scheme was
Constitutional Provisions, Evolution and launched in 1977, wherein training of community health,
Challenges for Comprehensive Primary Health reorientation training of multipurpose workers, and linking
Care in India medical colleges to rural health was initiated. To initiate
community participation, the community health volunteer
The Constitutional provisions (Schedule 7 of article 246) “Village Health Guide” scheme was launched. The Alma-Ata
are classified into three lists, including a Concurrent list Declaration of 1978 launched the concept of health for all
which both centre and states can govern but the overriding by year 2000. Alma-Ata declaration led to formulation of
power is with the centre. Central List (list includes original India’s first National Health Policy in 1983. The major goal
numbers): 28. Port quarantine, including hospitals connected of policy was to provide universal, comprehensive primary
therewith; seamen’s and marine hospitals 55. Regulation of health services. Nearly 20 years after the first policy, the
labour and safety in mines and oilfields State List: 6. Public second National Health Policy was presented in 2002. The
health & sanitation; hospitals & dispensaries 9. Relief for National Health Policy, 2002 set out a new framework to
disabled & unemployable Concurrent List: 16. Lunacy and achieve public health goals in socioeconomic circumstances
mental deficiency, including places for the reception or currently prevailing in the country. All five-year plans had
treatment of lunatics and mental deficient 18. Adulteration of overly ambitious plans but fell short of the set targets and
foodstuffs and other goods. 19. Drugs and poisons, subject to never were a corrective measure taken. In last 7 decades of
the provisions of entry 59 of List I with respect to opium 20A. independence, we have seen much improvement in primary
Population control and family planning 23. Social security healthcare services, infrastructure, and related healthcare
and social insurance; employment and unemployment. 24. indices of the country. Still many challenges are ahead
Welfare of labour including conditions of work, provident to achieve health for all [3]. Realizing the need to review
funds, employers’ liability, workmen’s compensation, primary healthcare in the country to know our strengths and
invalidity and old age pensions and maternity benefits 25. weaknesses to face the challenges in the future, India has
Education, including technical education, medical education committed for Comprehensive Health care in the National
and universities, subject to the provisions of entries 63, Health Policy 2017 to achieve Sustainable Development
64, 65 and 66 of List I; vocational and technical training of Goals (SDGs) through Universal Health Coverage (UHC) [4].
labour.] 26. Legal, medical and other professions 30.Vital
statistics including registration of births and deaths [2]. Current National Health Policy 2017

In India concept of primary healthcare was laid down by National Health Policy 2017 [4] is in place with a Goal
the recommendations of Bhore Committee as early as 1946. of the attainment of the highest possible level of good health
Bhore committee report laid emphasis on social orientation and well-being, through a preventive and promotive health
of medical practice and high level of public participation. care orientation in all developmental policies, and universal
With beginning of health planning in India and first five-year access to good quality health care services without anyone
plan formulation (1951-1955) Community Development having to face financial hardship as a consequence. Public
Programme was launched in 1952. It was envisaged as Health care services consist of preventive, promotive,
a multipurpose program covering health and sanitation curative and rehabilitative services. For the first time in
through establishment of primary health centres (PHCs) Indian Public Health history NHP 2017 has committed for
and sub-centres. By the close of second five-year plan (1956- providing at least 6 hours OPD case management in 150,000
1961) Health Survey and Planning Committee (Mudaliar Health and Wellness Centres (HWCs) across the country.
Committee) recommended to limit the population served by Health and Wellness Centres are envisaged to deliver an
the PHCs with the improvement in the quality of the services enlarged range of services to address the primary health care
provided and provision of one basic health worker per needs of the entire population in their area, expanding access,
10,000 population. The Jungalwalla Committee in 1967 gave ensuring universality and equity close to the community.
importance to integration of health services. The committee These services in HWCs will be provided through a Mid-level
recommended the integration from the highest to lowest Health Care Provider (MLHP)/Community Health Officer
level in services, organization, and personnel. The Kartar (CHO) placed at each HWC-SHC and Medical Officer at PHC
Singh Committee on multipurpose workers in 1973 laid (Rural/Urban).
down the norms about health workers. Shrivastav Committee
(1975) suggested creation of bands of paraprofessionals As on 31st March 2019, there were 157411 Health
and semi-professional worker from within the community Sub Centres (HSCs), 24855 Primary Health Centres (PHCs)

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 4 Journal of Quality in Health care & Economics

and 5335 Community Health Centres (CHCs) in rural

areas functioning in the country [5]. The HWC at the sub A. Existing Services to continue:
health centre level would be equipped and staffed by an 1. Care in pregnancy and childbirth.
appropriately trained Primary Health Care team, comprising 2. Neonatal and infant health care services.
of Multi-Purpose Workers (male and female) & ASHAs and 3. Childhood and adolescent health care services.
led by a Mid-Level Health Provider (MLHP). Together they 4. Family planning, Contraceptive services and other
will deliver an expanded range of services encompassing Reproductive Health Care services.
reproductive and child health services, communicable 5. Management of Communicable diseases including
diseases, non-communicable diseases, palliative care and National Health Programmes.
elderly care, oral health, ENT care, and basic emergency 6. Integrated Disease Surveillance
care4. A Primary Health Centre (PHC) that is linked to a B. Expanded services to be initiated at Community:
cluster of HWCs would serve as the first point of referral 7. Daily Outpatient care for acute simple & minor
for many disease conditions for the HWCs in its jurisdiction. ailments.
The Medical Officer at the PHC would be responsible for 8. Screening, Prevention, Control and Management
ensuring that CPHC services are delivered through all HWCs of Non-Communicable diseases.
in her/his area and through the PHC itself. The number and 9. Care for Common Ophthalmic and ENT problems.
qualifications of staff at the PHC would continue as defined 10. Basic Oral health care.
in the Indian Public Health Standards (IPHS). Majority of 11. Elderly and Palliative health care services.
secondary and tertiary care facilities in public sector will 12. Emergency Medical Services.
also provide primary health care. Apart from public sector 13. Screening and Basic management of Mental
facilities there are thousands of private sickness care health ailments.
providers both formal including Allopathic, Ayurveda, Yoga,
Unani, Siddha Homeopathy systems and other traditional Figure 1: Range of services.
and informal service providers.

Burden of Illness in Rural and Urban India The average medical expenditure incurred per spell of
ailment indicated that, people spend from INR 327 (Govt.) to
As per NSSO 75th round report (2017-18), the 1081 in Private hospitals, the private clinics (564) and Trust
proportion of persons that responded as ailing (PPRA) was hospitals cost 624. The breakup of the components on which
7.5% of the (9.1% among urban and 6.8% among rural) the expenditure was made indicated that most of the money
population during last 15-day reference period of the survey was spent on Medicines (54-82%), followed by Diagnostics
[6]. Gender wise PPRA indicated the proportion to be around (11-29%), Doctor’s fee and others. In the Govt. sector first
6.7% male in and in female-8.3%. The PPRA ranged between 2 items costed 93% and the doctor’s fee-15% in pro-profit
less 3% in Assam and Bihar to a highest of 24.5% in Kerala. facilities.
While six states of MP, Karnataka, Chhattisgarh, Rajasthan,
Telangana, Haryana had the PPRA in the range of 3-5.9 %. The inclination towards seeking sickness care was
Another six namely Tamil Nadu, Gujarat, Jharkhand, UP, clearly highest towards allopathic treatment as over 95% in
Maharashtra, Odisha had a PPRA of 6-8.9% respectively. both the sectors sought allopathic care. Less than 5% sough
Punjab, West Bengal, Andhra Pradesh had the PPRA of 10.0- care in AYUSH system facilities. More than 65% (62% in rural
14. Age specific ailment reporting was highest of 27.7% and 71.5% in urban) spells of ailment were treated in the
among persons aged 60 years and above followed 11.4% private. Govt. /Public facilities catered only 32.5% and 26.2
among 40-59 years, 8.5% among under-fives, 5.4% among % in rural and urban areas respectively.
20-39, 4.8% among 5-14 years and least among 15-29 aged-
3.3%. Similar trend was observed among both genders. An overall 29 persons (Urban-34 and Rural 26) per 1000
people fell sick sought hospitalization (in 365 days). Kerala
Broad category of illnesses (Figure 1) indicates that reported the highest proportion 105/1000. Hospitalization
both in Urban (35.7%) and rural (25.4%) area infections proportion was 111/1000 among persons aged over 70
were dominant, followed by cardiovascular diseases. While years, followed by 72 in 60-69 years and 27 among under-
metabolic disease in urban areas were almost double fives. As I am looking at primary health care in this paper, I
compared to rural area. It is also evident that the proportion am not detailing the care of hospitalized.
of CVDs and Metabolic diseases was significantly higher in
urban areas. Health Insurance/assurance coverage was poor as 81%

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 5 Journal of Quality in Health care & Economics

of urban population and 86% in Rural Population was not Why Comprehensive Primary Health Care
covered by any health insurance scheme. Percentages of Facilities matter
persons in different quintile class of household having some
form of health expenditure coverage ranged from 10%- Healthcare facilities are the basic building blocks
22% in Rural India and from 10-33% in Urban India, 4th of a health system. A healthcare facility is designed to
and fifth quintiles in urban area showing better insurance provide a certain type of services based on the size of the
coverage. Among the covered 13.5 % in Rural and 12.2% in local population and epidemiological pattern of the health
Urban area were covered by Govt. funded insurance scheme. conditions of the area.
In urban areas only 3.8% by households had insurance
with companies, 2.9% by employer funded schemes and a. Public Sector Primary health care set up (Figure 2)
remaining 0.2% by others. The contribution of these three in India provide the essential preventive and curative
insurance schemes was only 0.6% in rural area. care required to address the most prevalent conditions,
including reproductive and maternal health, child health,
Overall percentage of persons with disability in the nutrition and diagnostic and treatment services for most
population was 2.2 percent [7] (with 2.3 % in rural and 2 common conditions. It is also from these PHC facilities
% in urban areas) during July 2018 to December 2018 in that we run public health programs and community-
the country, as per a National Statistical Office (NSO) survey based programs using community health workers like
report on 23 November 2019 [6]. Locomotor disabilities {Accredited social health activists (ASHA’s) Anagnwadi
dominate with a share of 1.1% of the population, followed workers (AWWs), Traditional Birth (TBAs) Attendants
by hearing disability of 0.3%, visual disability, speech and and other community volunteers}. NHP 2017 brought
language disability and mental retardation or intellectual about one another initiative of bringing all AYUSH health
disability (0.2% each) and 0.1% each of mental illnesses facilities that were running as vertical facilities until
and other disabilities. All these needs to be considered for 2013 getting integrated strategically Under NHM at the
planning Comprehensive Primary health care services. primary and secondary care level facilities recently. The
process is on and yet to see total integration across the
country.

Figure 2: Break up of aliments by nature of aliment, all-India.

The patients with less frequent or serious conditions big cities depending on geographic accessibility. In an
that require specialized diagnostic and treatment services extraordinary decision Govt. of India has made provision to
are referred to secondary care (sub-district & district) hire such services from the market if they are not available
hospitals where more complex medical technology can be in the nearest public health facility under National Health
accessed and basic specialists like Physicians, surgeons, Protection Scheme popularly known as Ayushman Bharat
Paediatricians and Obstetrician and Gynaecologists provide [7,8].
services. Specialized hospitals that deliver tertiary and
even quaternary levels of care for trauma, cancer, burns, b. Public Sector Health Services in Urban areas:
cardiac surgeries etc. are in state capitals and some other Primary Health Care for urban areas was not given its

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 6 Journal of Quality in Health care & Economics

due importance since independence. Many vertical and supervision framework and partnership with non-
programs did have a component of urban planning and governmental providers for closing gaps in health delivery
were implemented through multiple agencies like Urban gaps in the urban sector.
Health and Family Welfare centres, Post-partum centres
under All India Postpartum Program, Urban Malaria
program, Urban Leprosy units, Tuberculosis program,
HIV/AIDs etc. The sickness care was traditionally
provided to the urban poor population through municipal
dispensaries, urban PHCs and clinics. Supplementary
preventive and promotive health services are also
available through School Health Clinics, Bal wadi’s and
urban ICDS centres run by the State Women and Child
Welfare Departments. Most of the secondary and tertiary
facilities like maternal and child health hospitals (run by
Municipal Administration state Health & Family Welfare
department) Central Government Health Services
(CGHS), Employees Sate Insurance Scheme (ESIC)
Railways hospitals and Defence hospitals and infectious
diseases hospitals also provide primary health care for
their select clientele. Government of India with the help
of soft loan from the World Bank under Health system
strengthening projects between mid- 1980’s to 2000 Figure 3: Primary health care structure.
established urban health posts, Primary Health centres
and referral hospitals in major cities like Mumbai, Delhi,
Kolkata, Chennai, Bengaluru and Hyderabad, that are Private Sector
under the administrative control of local Municipal
corporations. Health service delivery challenges include i) Rural Private Health Sector: The apathy of public doctors
i) Skewed distribution of public health facilities leading leads to unregulated private practitioners in health sector.
to lack of coverage ii) Lack of urban health promotion Many of them are quacks, who work for 6 months to one year
towards better access iii) Multiplicity of Service Provides with a qualified doctor and then start their own independent
and lack of Coordination & Convergence (among Govt. practice often rendering services in the houses Figure 4.
of India/State Government/ Municipal Corporation / Countrywide less than 26 % (U)-32% (U) of households
Municipalities and NGO sector) iv) Inadequate policy & depend on public facilities. Nearly 68 % of rural households
infrastructural capacity to deal with swelling migrant receive medical care from private practitioners. 42% of those
and urban poor populations. classified as allopathic doctors in rural areas, have no medical
training. This proliferation of unregulated and unqualified
After the launch of National Health Mission in 2013 [8- private providers demands an effective regulatory system
16], a formal Primary health care structure was set up (Figure (India Development Report, 2012/13). 80% of general
3) for Universal Health Coverage (UHC). They are coming up practitioners practise allopathic medicine without proper
in all categories of towns & cities, though the take-off has been training [5].
slow across the country. Structural Problems currently being
addressed include a) Catchment areas for the specific health ii) Private sector in Urban India: Urban health care services
facilities are not well defined b) Inadequate focus on Primary are mainly dominated by Private facilities ranging from
health care facilities c) Governance-Fragmentation of health Jhola Chhap (mobile quacks- door to door service provider)
care services under different government departments and registered medical practitioner (RMP) to super-specialists.
local bodies and Low use of technology for data collection The complexity of private health care in urban areas
and integration of services. Equally challenging are the increases as the size of the town/city increases. Host of
solutions such as revamp the existing facilities with ensuring Private health providers including Private Medical colleges,
one “primary urban health centre with outreach and referral pro-profit corporate hospitals and nursing homes and clinics
facilities’, rationalizing urban primary health structure, run by family physicians are the hallmark of the urban health
introduction of a public health management cadre and health services. Bigger cities will also have some Trust & Charitable
systems management cadre, strong regulation, accreditation, Hospitals.

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 7 Journal of Quality in Health care & Economics

Figure 4: Rural health care system in India.

The primary care in urban areas, is dominated by the 3. Primary health care implemented in a timely and helpful
single practitioner clinics and unqualified practitioners. manner can also reduce the need for specialist care,
The markets where these providers operate are fragmented which may be unnecessary and have the potential to
and unregulated. The quality of care is also questionable. harm patients.
The recent studies in most metropolitan cities and state 4. The facilities are close to the community, thereby reduce
capitals revealed that the quality of care is low in the the commuting time & cost.
poorer neighbourhoods. The care differed with difference 5. They are the backbone of our health system providing
in incentives (income and reputation) and competencies greater access to needed medical services; good quality
amongst the providers. It was also noted that rich availed of care; early management of health problems and
the services of the more competent doctors and the poor had more focus on prevention of diseases -leading to lower
access to lower quality of doctors. Though the urban poor morbidity.
are not restricted geographically in accessing these health 6. The Public sector UHC facilities (HWCs) as envisaged
facilities, lack of money is a barrier to care. under NHP 2017 can provide free primary health care
without many hassles. That will lead to many people
Private Sector provides care to 70% of outpatient visiting the doctor that will result in improved prices
episodes of which Private Hospitals contribute (62%), as the cost will be dependent on the value of excellent
Nursing Homes (24%), Charitable Hospitals (3%), Corporate service given to a patient rather than the number of
Hospitals (2%), Others (1%), In terms of service providers services offered to a patient
Medical & Dental constitute (52%), AYUSH Doctors 7. Primary care practitioners can recommend screening
(10%), Diagnostic Labs, ISM hospitals (14%), Nursing & measures to detect early changes that could be
Physiotherapy (2%) and Others (2%) [9]. indicative of specific diseases. This may include checking
blood pressure, blood tests, breast examinations,
The primary health care facilities matter in India health mammograms, Pap smears and bowel cancer screening.
system because: 8. Most importantly they will reduce the unnecessary
1. The Primary care is known to place a greater emphasis burden on secondary and Tertiary Hospitals,
on the health of the whole person rather than a specific Convenience for those who need their attention and the
organ or system, which may contribute to positive effects waiting time.
such as reduced mortality rates due to the accumulated 9. It is in this context that this review is undertaken
contribution of the care. to analyse the challenges of making Comprehensive
2. The close and ongoing relationship between patients and primary health care a reality and suggest way forwards
their primary care providers helps health professionals to make the best opportunity Ayushman Bharat has
to understand their situation more completely and make provided.
the relevant recommendations.

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 8 Journal of Quality in Health care & Economics

Materials and Methods Delhi, Luck now, and Patna. In each district different level
stakeholders were interviewed {(ASHA &AWW at Villages,
The current paper seeks to pinpoint key challenges of Health Assistants M&F at Health Sub centres, Medical officers
fixing the Comprehensive Primary Health Care, particularly at PHCs and CHCs and Dy. CMOH &CMOH at district level and
Sickness Care at public sector primary health care facilities Director, joint directors at the state level). Similarly, in urban
and governing private primary health care at the community areas ASHAs, AWWS, HA’s (Jr & Sr-M &F), MOS and municipal
level. It also discusses about the possible strategies to be taken health officers were contacted and filed observations at
forwards by the state and local government for overcoming Urban Health centres were made.
the quality and cost-efficient services of the private sector.
This is a review paper based on analysis of 1) secondary Activity Wise Scope
sources like GOI and sates portal platforms i.e. AB-HSCs
progress, Stare NHM sites, 1.http://bit.ly/33QiIAk, 2. http:// The overall focus of this study was baseline evaluation
bit.ly/2zdkMUV, http://alfa.nic.in/const/ schedule.html of twenty-two activities of HSS2, mostly a qualitative focus
2) NSSO reports on reported illnesses (NSSO 75th round), to evaluate the baseline of Health System Strengthening
Disability Report (NSSO 76th round report), books, NGO Support (HSS2) 2nd project of UNDP to India, for routine
reports , few published articles over last 50 years in journal Immunization system strengthening and implementation.
articles, and 3) Filed assessments and observations, health Since the HWCs establishment was in its’ initial adoption/
facility records and interaction with stakeholders at different adaption stage we added five basic questions in interviews
levels in last 15 months (September 2018-Decmeber 2019). and observed certain functions at all levels of the health
Filed visits were made as a part my professional consultancy system. The study did not focus on beneficiary level feedback.
work that took me to 7 states, 10 districts and 5 cities in
India during the said period. 4) Literature research of two Data Collection Methodology
MPH scholars Mr. Rashid and Ms Priyanka from KSRDPRU
Gadag for their Dissertation work on a) Status of HWCs in The primary data for this component of the study was
Gadag and b) Availability of Generic lifesaving drugs in Gadag collected by 2 methods: 1. Questionnaire: five questions that
and Kushtagi, respectively Karnataka -November-December included were i) Status of the State government order of
2019. sanctioning up gradation of HSCs & PHCs into HWCs and if
sanctioned their definition of functioning ii) If the population
Study Setting to be covered by such HWCs in urban areas were mapped
out iii) The physical infrastructure identified, assessed for
Seven States across India namely Uttar Pradesh, Bihar, additionalities required iv) Human source recruitment and
Madhya Pradesh, Maharashtra, Karnataka, Delhi, and training process v) Orientation of state/district/ city and
Haryana. This study was taken up along with another study local level started 2) On site interaction with staff recruited
for UNDP supported project assessment where the author and observation of the activities like function OPD, Antenatal
was a team leader. clinic, laboratory services, drug dispensing, outreach services
provided if any etc.
Sampling & Sample Size
Data Analysis
Sampling of districts were done in consultation with
state level officers, representing one typical and another Since the number of total units were only about a dozen,
tribal or remote district and ease of commuting for the the data for questions were analysed in an excel sheet and
primary objective. the qualitative components of the functionality recorded
for each of the units visited. FGD’s of the staff gathered for
Geographical Scope a weekly meeting were done where possible. No video or
audio-recording was done of the interviews or FGDs done
The primary data collection through field level during the entire process.
consultation was carried out in five states of Uttar Pradesh,
Madhya Pradesh, Bihar, Delhi, Haryana, Maharashtra, and Results
Karnataka covering two districts in each state and one urban
area. The districts covered included Gaya and Patna in Bihar, From literature Review
South west and North Delhi slums, Gurgaon and Faridabad in
Haryana, Bengaluru urban districts and Gadag in Karnataka, The design of HWCs and the delivery of services build on
Jhabua and Bhopal in MP, Agra and Barabanki in UP. The the experiences and lessons learnt from the National Health
urban areas included cities of Bengaluru (BBMP), Bhopal, Mission, India’s flagship programme for strengthening

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 9 Journal of Quality in Health care & Economics

health systems. Expanding the scope of these components to numbers look impressive, their functional status in terms of
address the expanded service delivery package will require physical infrastructure, manpower, equipment, drugs, and
reorganization of work processes, including addressing the other logistical supplies that are greatly needed for ensuring
continuum of care across facility levels; moving from episodic quality services is a matter of concern. Among the key
pregnancy and delivery, new-born and immunization facilities which are going to be upgraded as HWCs, the status
services to chronic care services; instituting screening and of HSCs and PHCs is not rosy as 20% of them don’t have their
early treatment programmes; ensuring high-quality clinical own building, 25% do not running water supply, one third
services; and using information and communications of them do not have electricity and 10% of them do not have
technology for better reporting, focusing on health all weather roads6. Sixty per cent of primary health centres
promotion and addressing health literacy in communities. (PHCs) in India have only one doctor while about five per cent
The national and State governments did realize and spelt out have none [9]. A recent study in Nellore district of Andhra
clearly that although there will be major challenges ahead Pradesh indicated that the deficiency of AYUSH medical
to meet these ambitious goals, it is important to capitalize officers was 86.6% and the deficiency of health workers
on the current high level of political commitment accorded (female) was 13.33% [13]. Some of the important drugs
to comprehensive primary health care4 and strengthening such as antihypertensive, anticonvulsants, emergency drugs,
public sector health care services and purchasing the services drops, ointments, and solutions were available in less than
not available in public sector from the private providers 50% of the PHCs. Only 47% of the PHCs had Typhi-dot tests
under Ayushman Bharat. and H2S test strips to assess the water contamination, and
in the labour rooms only 20% of the PHCs have a Standard
The fact of the matter is NHP 2017 clearly recognized that Surgical Set for episiotomies in accordance with IPHS.
healthcare in Rural India faces major challenges of quality,
accessibility, and affordability for a large section of the The first Health and Wellness Centre (HWC) under
population. The key limitations identified were i) shortage of Ayushman Bharat was inaugurated by the Prime Minister
qualified healthcare professionals and services like qualified Shri Narendra Modi at Jangla in Bijapur Chhattisgarh
doctors, nurses, technicians as evidenced by the presence of on 14thApril 2018. Since then 10,252 HWCs have been
0.76 doctors and 2.09 nurses per 1,000 people {as compared operationalized. The states of Andhra Pradesh, Tamil Nadu,
to World Health organization (WHO) recommendations of 1 Uttar Pradesh, Karnataka and Kerala lead the way with the
doctor and 2.5 nurses per 1,000 population respectively}, and highest number of HWCs under Ayushman Bharat. Andhra
ii) infrastructure- Indian healthcare faces acute shortage of Pradesh has operationalized 1361 HWCs, Tamil Nadu 1318,
hospital beds with 1.3 hospital beds per 1,000 population as UP 912, Karnataka 700 and Kerala 678 HWCs. These HWCs
compared to WHO recommended 3.5 hospital beds per 1,000 have been categorised as Sub Health Centres (SHC), Primary
population [9-11]. Non-uniform accessibility to healthcare Health Centres (PHC) and Urban Primary Health Centres
across the country, physical access continuing to be the major (UPHC). As of 11 December 2019, out of total HWCs of
barrier to both preventive and curative health services, and 39069, HSC upgraded number was 19577, PHCs upgraded
glaring disparity between rural and urban India. Most of the were 16238 and Urban PHCs upgraded were 3254.
private facilities are concentrated in and around tier 1 and
tier 2 cities, due to which patients must travel substantial According to the Economic Survey 2019-20, report
distances for basic and advanced healthcare services [9]. tabled in Parliament on Friday by Finance Minister Nirmala
Sitharaman on 31 January 2020, reported that a total of
India has a vast public health infrastructure with 28,005 such centres have already been set up as on January
23,391 primary health centres (PHCs) and 145,894 Health 14, 2020 (source- Economic Times -31 January 2020) (Table
subcentres (HSCs)providing health services to 72.2% of 1).
the country’s population living in rural areas. Although the

Description India Karnataka

Footfall- 3,10,92,556, 1085957
HT patients- treated 69,41,364 39316
Diabetics treated- 38,17,736 58340
Yoga sessions conducted 2,03,727 11628,
Persons screened for Breast Cancer 82,45,292, 20931
Persons screened for Cervical Cancer 49,79,183 7733
Persons screened for Oral Cancer 1,22,17,040 164,843
Table 1: Service deliveries.

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 10 Journal of Quality in Health care & Economics

From Primary Sources & Field Observations and 219326 were working with a shortfall of 27964 (13%).

• All the states had issued Go’s for the first set of districts As on March 31, 2018, at least 60 per cent sub centres,
to upgrade HSC s & PHCs to HWCs 18 per cent PHCs and 12 per cent CHCs in India were without
• Since most of UPHCs and HSCs in urban area were of staff toilets as against the WHO’s mandate of basic sanitation
recent origin, no further order was explicitly issued in facility at a health care centre should include at least one
any of the states visited. Three of the states also felt that toilet dedicated for staff, at least one sex-separated toilet
converting HSCs into HWC’s in cities is non-viable for with menstrual hygiene facilities, and at least one toilet
want of physical infrastructure and difficulty in getting accessible for people with limited mobility. Nearly 61% govt
space for the same. health centres in rural India don’t have separate toilets for
• In the UPHC the area and population to be covered women. In Kerala and Telangana, 86% rural health centres
was indicated, but majority had not mapped their don’t have sex-separated toilets. As on March 31, 2018,
geographical boundaries. None of the UPHC had there were 26,360 sub centres and 1,313 primary health
demarked areas for ASHAs for mobilization activities centres in rural India that did not have a regular source of
and some for even Health workers for service provision water as against the WHO’s recommendation of availability
• The districts were struggling to freeze the list of HSCs of sufficient quantities of safe water is important for health
and PHC for up gradation due to political pressure a centres to provide quality services9. Manipur leads this list
common feature in India with 79 per cent sub centres devoid of regular water supply,
• The most remote and needy HSC were not considered followed by Mizoram (62%) and Meghalaya (60%). Among
in the first lot selected for up gradation, leaving those large states, Bihar has 49 per cent sub centres without
unreached or under-reached regular water supply, Jharkhand (53%), Rajasthan (34%)
• The state and district level officers were oriented about and Odisha (30%). Uttar Pradesh, Telangana, Goa and Tamil
the concept of HWCs either by National or Regional Nadu are among states where all sub centres have regular
workshops water supply.
• Two states had frozen the qualification for MLHP (BSc.- Sub centres are the smallest units in India’s rural health
nursing), recruited and training started. infrastructure under the charge of an ANM (auxiliary nurse
• The assessment of the identified institutions for midwife) to ensure availability of last mile trained medical
additional inputs was not yet initiated. services in rural areas providing all primary healthcare
• The capacity development modules for the additional services. A PHC on the other hand is a government hospital
tasks to be performed at the HWCs level (or better with 6 beds that acts as the first contact point with local
integrated modules) were in discussions at national community and generally caters to around 25 villages
levels only under the charge of a qualified MBBS doctor assisted by a
• No concrete strategy for capacity building especially for pharmacist, 4-5 nurses and other medical staff. PHCs treat
the para-medical Primary health care providers was yet patients with routine illness and are also equipped to handle
developed delivery cases, organise sterilisation camps etc. A CHC is a
• At the health sub-centres, no, new activities had yet much bigger hospital, generally with 30 beds and 5 medical
begun, especially fulfilling the provision of running OPD experts, including a surgeon and more than 10 nurses. A CHC
for 6 hours a day. covers nearly 120 villages.
• Paucity of Jan Aushadhalayas, that have just opened in
1-2 number per district and Taluka level for accessing NHP 2017 has incorporated 7 Key Policy Shifts. Of them
lifesaving=generic drugs at reasonable cost and nearly four are clearly in the areas of fixing primary health care a)
two thirds of drugs procured for free distribution in Ensuring comprehensive primary Health Care (CPHC) care
public sector hospitals are generic drugs. that has continuity with referral facilities at higher levels by an
appropriate referral mechanism, b) It assures free, diagnostic
Discussions and emergency services to all seeking care in public health
facilities, c) targeted Infrastructure & Human Resource
The status of shortfall in health facilities as per 2011 Development to reach under-serviced areas throughout the
population in India indicates that as against the number of country. d) It has recommendation of specific plans to scale
PHCs required 29337 in position were 25743 and a short fall up health services in urban areas with a focus on urban poor
6430 (22%) and CHCs required were 7322, in position 5624, and establish linkages with national programs, from what
shortfall 2188 (30%) as per Rural Health Statistics (RHS), was a token under-financed intervention in all previous
2018, as on 31.03.2018, as per Minister of State (Health and national health plans. It also envisages achieving convergence
Family Welfare) written reply in the Rajya Sabha here on 23- among various departments and agencies responsible for
July-2019. The number of ANMs sanctioned were 216665 wider determinants of health urban population e) a three-

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 11 Journal of Quality in Health care & Economics

dimensional mainstreaming of hither to stand-alone AYUSH management of fever cases assuming that every case is case
system of medicine for better cafeteria approach of service of malaria unless proved otherwise in 1953. Then came the
provision4 Currently There is skewed human resource as one management of diarrhoea cases through Oral Rehydration
sees from the figure. While 66% of population is in rural area Therapy (including ORS) at community & sub centre level in
only 33% of qualified doctors are there. On the converse the 1980’s. Later expanded to include Pneumonia management
urban area has 34% of general population catered by 67% in 1990’s and standalone new-born care and Integrated
of doctors. As a result, we see 79% of urban population and management of neonatal and childhood illnesses (IMNCI) at
72% rural population are treated in private sector. the homes and facilities in early 2000.

There may be a lot of attention on improving tertiary The NHP 2017 envisages Comprehensive Primary Health
healthcare in India but, healthcare in rural areas remained Care at Sub-centre level. Client satisfaction is the strategy
a concern according to the Economic Survey 2018-19, tabled followed & all clients are treated equal. The brand equity of
in the Parliament on July 4, 20199 as Sixty per cent of primary the public health services is poor in India according to many
health centres (PHCs) in India have only one doctor while users and non-users. The basic doubt is about the quality of
about five per cent have none. Gujarat emerged the worst services and human behaviour of the service providers and
performer, with more than 90 per cent PHCs having just one of course irritants like long waiting time, the feeling that
doctor. The state was followed by Kerala and Karnataka (80% unless you know someone in the facility you are not cared
each) and Rajasthan, UP and Bihar (70 % each). More than 10 for restrict the use of the services. But the lower middle class
% PHCs in Jharkhand and over 20 % in Chhattisgarh function and poor population have no choice as the private services
without doctors, the Survey stated. How can a health system are not affordable. The new UHC with free comprehensive
in States with large number of PHCs functioning with just PHC and providing secondary and tertiary care through
one doctor or without a doctor ensure 24X7 basic services? health assurance scheme will establish customer equity
Besides the lack of doctors, participation of healthcare staff that is the sum of the customer’s lifetime value across local
was also found to be disturbing. customer basis. Therefore, individual care centres must
have to struggle to get back the clients by not only providing
The roll out plan of AB - HWCs was given as: FY 2018- available services, but also advising referral to appropriate
19 = 15,000, FY 2019-20 = 25,000 (Cumulative 40,000), facilities so that these customer-centric recommendations
FY 2020-21 = 30,000 (Cumulative 70,000), FY 2021-2022 help lock in the clients for long as effectively as the quality of
= 40,000 (Cumulative 1,10,000), Till 31st December 2022 services themselves.
= 40,000 (Cumulative 1,50,000). Looking at the progress
achieved by early 2020 one hears that against the target of Reviewing the process of empowering para-medical
40,000 AB-HWCs by FY 2019-20, approvals for more than workers for curative services, that started with dispensing
62,000 AB-HWCs were given to States/UTs and only 28005 drugs for Malaria introduced in 1953. The then malaria
(70%) AB-HWC was functional as on 30.01.2020, as per AB- workers were trained to take blood smears for all fever
HWC portal. We believe that the definition of functioning cases during active surveillance and provide Chloroquine
units may be different in different states. No wonder if most tablets as prophylaxis based on the age of the client and
of them are on paper and at the most had changed the sign complete the recommended radical treatment if the Blood
boards with no additional inputs so far [8]. At this speed smear turned positive after microscopic examination. The
it may take another 5 years to reach the target of 150,000 concept of Multipurpose Health Workers (Male and Female)
HWCs. was introduced in 1974 for the delivery of preventive and
promotive health care services to the community at the level
The selection process of HSCs and PHC and UPHCs of Sub-Health Centres (SHCs), the most peripheral health
for up gradation into HWCs suffers from bias of selecting facilities, covering 5000 population in plains and 3000
the easily accessible or with political clout at least in the population in hilly/ tribal/ difficult areas. The Multipurpose
initial first two years. The most remote, hilly or tribal HSCs Health Worker (Male) was the grass root health functionary
and PHCs and unrecognized urban slums did not get the for the control of communicable diseases including Malaria,
opportunity of investments in Health. One would have liked TB, Leprosy, Water Borne Diseases, as well as Environmental
20% of HSCs that don’t have their own building, 25% who Sanitation, detection of disease, outbreaks and their control,
do not have running water supply, one third of them who health education etc. MPHW (Male) will mainly focus on
do not have electricity and 10% of them who do not have activities which are related to disease, control programs,
all weather roads got priority in setting up HWCS [14]. The detection and control of epidemic outbreaks, environmental,
Public sector follows “Product Centricity” strategy with sanitation, safe drinking water, first aid in emergencies like
Long-term focus on strengthening the product portfolio and accidents, injuries, burns, etc., treatment of common/minor
constantly finding to new ways to expand it. It started with illnesses, communication and counselling, lifestyle diseases

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 12 Journal of Quality in Health care & Economics

and logistics and supply management at sub-centre. In care for the elderly, and medical emergencies with provision
addition, he was to also facilitate ANM in MCH, Family Welfare, of Wide range of free drugs, Point of care diagnostics at the
and Nutrition related activities. The training curriculum centres, Tele-consultation services with Medical Officers for
included 20 hours of theory and 32 hours of practical for complications, Continuum of care ensured through referral
minor ailments treatment. In view of the resurgence of linkages and protocols, Unique health id – longitudinal health
Malaria and introduction of Multi-Purpose Workers (MPW) record for each individual, Services related to indigenous
scheme in early 1974 the task of treatment of malaria cases health system and yoga for promotion of wellness. The
was entrusted to ANMs also since 1974-75. itemised progress can be summarized as

The Integrated Child Development Scheme (ICDS) was Human Resources

launched on 2 October 1975 in 33 (4 rural, 18 urban, 11 tribal)
blocks was reinforcing the health sector human resource at At all H&WC’s a team of at least 3 service providers (1
the community level for complementing health services. MLHP, 2/3 Multi-Purpose Workers (2 Fe & 1 M) & team of
Over the last 25 years, it was expanded progressively across ASHAs at the norm of 1/1000 population will be stationed.
the country with more than 1.3 million AWCs in early 2020. In urban areas, the team would consist of the MPW-F (per
From 1975 Anganwadi centres. Set up by the department of 10,000 pop.) and ASHAs (1/2500 pop). In most sanctioned
Women and Child welfare specifically for maternal and child centres the posts are created but more than 50% of the new
health care and monitoring early childhood development posts are yet to be filled in.
specially to cover most disadvantaged population. The
package of services consisted of i)Complementary nutrition, At the strengthened 24*7 PHCs having inpatient care,
ii) Vitamin A, iii) Iron and folic acid tablets, iv) Immunization, an additional nurse apart from IPHS standards would be
v) Health check-up, vi) Treatment of minor ailments, vii) posted where cervical cancer screening is being planned. In
Referral services, viii) Non-formal education on health and PHCs that are not envisaged to provide inpatient care, the
nutrition to women, ix) Preschool education to children 3-6 existing nurses would receive modular training in primary
year old and x) Convergence of other supportive services like care. Less than 10% of the PHCs have started screening for
water, sanitation etc. Around the same time Health ministry cancers are it cervical, breast or oral.
also recruited community volunteers and trained them for
primary health care or minor ailments treatment. Diarrhoeal Logistics
diseases control program launched in 1978 for better case
management in 1978 lead to focus shifting to strengthening To resolve more and refer less at the local levels, and
case management of diarrhoea for children under the age of to enable dispensation of medicines for chronic illnesses
5 years and national ORT program was introduced in 1985- continued availability of essential medicines and diagnostics
1986. In 1990 Acute Respiratory Infection Control program to support the expanded range of services will be ensured.
launching in 1990, was the real capacity building for early No significant difference is visible still in the drugs logistics.
diagnosis and treatment for the multipurpose workers.
Introduction of Integrated Management of Neonatal and Infrastructure
childhood Illnesses (IMNCI) in 1994 with the support of
UNICEF India and WHO was the real capacity building It is proposed to make available sufficient space for
exercise for health workers in India. The scheme was outpatient care, pharmacies for dispensing medicines,
expanded to entire country by 2000, but it lost it sheen in catering diagnostic services, display of communication
2008-10 mainly for want of logistics and field level support. material and to use audio visual aids on site and space for
In 2005 Accredited Social Health Activists (ASHA) were wellness activities-the practice of Yoga & physical exercises.
introduced for bridging the gap between health workers and Negligible additional spaces have been provided even if it be
community. temporary on rental basis.

The new ambitious Universal health Coverage through Digitization

AB-HWC (2018) plan envisages-Expanded package of
HWC teams will be equipped with tablets/smart Phones
primary care services-ranging from maternal and child health,
to facilitate the functions of population enumeration and
communicable diseases to non-communicable diseases
empanelment, recording of services delivered to enable
(universal screening, prevention, control and management of
quality follow up, referral/continuity of care and create an
five common communicable diseases: hypertension, diabetes
updated individual, family and population health profile.
and three common cancers-those of the oral cavity, breast
The gadgets will also help the local team to generate
and cervix) primary health care for diseases of the eyes, oral
periodical reports required for monitoring at higher levels.
health, ENT, mental health, provision of palliative care and

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 13 Journal of Quality in Health care & Economics

ANMOL- a palm top is being tried under immunization be provided to frontline workers, with the help of Mobile
system strengthening project with lots of starting troubles of Medical Unit’s. No progress.
training, maintenance, and internet connectivity issues.
Referral Services
Use of Telemedicine/ IT Platforms
Availability of referral care services either in Public
A long term dream is to promote at all levels, sector or private sector varies with each illness, its care
teleconsultation to improve referral advice, seek pathways and availability of specialists. For the acute illness,
clarifications, and undertake virtual training including case it is the Medical Officer in the PHC as a primary care provider
management support by specialists located in regional super and refer to appropriate level either for diagnostic facilities
specialty hospitals. Not yet initiated. or for the interventions beyond what can be done at that
level to the specialists in first referral units (FRUs-include
Capacity Building Community Health Centres/ Taluka/ Sub-district or district
hospitals) either physically transferring the patient or
An accredited training package in a set of primary through telephonic consultation. Over next decade, states will
healthcare and public health competencies for all mid-Level progress to establish First Referral Units at the CHC level, and
health providers and for other service providers to deliver hospitals having the full complement of specialists required
the expanded range of services at HWC, combining theory diagnostic and management facilities to the expanded range
and practicum with on the job training is being developed. of services at every district headquarters. As of now referral
Some states have finalized that category of people and job services are available in private sector for secondary care in
descriptions, recruited a few batches and they are under most of the districts towns and the super specialty hospitals
training as per state reports. None of such staff were seen in at regional levels. Specific referral mechanism is yet to be
the field. established.

Health Promotion Increased Access to Services

Capacity building among community level functionaries HWCs would provide access to an expanded range of
for behaviour change communication to address lifestyle services indicated in Box 2. The availability of services would
related risk factors and undertaking collective action evolve in different states gradually, depending on three
for reducing risk exposure, improved care seeking and factors- the availability of suitably skilled human resources at
effective utilization of services under polio eradication and the HWC, the capacity at district/sub-district level to support
routine immunization will be expanded to cover all other the HWC in the delivery of that service, and the ability of
interventions of UHC. Development of health promotion the state to ensure uninterrupted supply of medicines and
materials and engagement of community level workforce diagnostics at the level of HWC. States will also have the
like Village Health Sanitation and Nutrition Committee flexibility to expand the range of service to address local
(VHSNCs), Mahila Arogya Samiti (MAS), Self-Help Groups health problems as defined by disease prevalence. There
(SHGs) and NCC/ACC health ambassadors in schools will be are successful examples of organizing sickness care services
strengthened. Little progress is visible as the development under IMNCI and NBC since late 1990’s and it is possible
partners are putting together strategies and materials for to build suitable human skills. The ability of the states to
health promotion or behavioural change communication. support uninterrupted supply of diagnostics, medicines and
other supplies varies from state to state. Empowered Action
Community Mobilization Group (EAG) states like UP, MP, Bihar Assam may not be able
to meet this goal.
Built on the accountability initiatives under NHM so that
there is no denial of use of health care, universality and equity, On the other hand, Private sector is moving towards
community actions on social mobilization and mitigating Customer Centric Strategy. Customer Centricity is a strategy
environmental determinants, through intersectoral that aligns the corporate hospitals delivers their product
convergence efforts will be pursued. No concrete steps are and services with current and future needs of their patients
visible in this activity. of a select customer to maximize their long-term profit.
It is based on an understanding that not all customers
Linkages with Mobile Medical Units are created equal. Patient centricity develops sustainable
profit on the long term. The three key areas that helps are
In remote and underserved areas where there is difficulty i) Customer acquisition ii) Customer retention iii) Customer
in establishing HWCs, medicines and other support could development. It involves investment in the technologies, and

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 14 Journal of Quality in Health care & Economics

human capacity necessary to collect and analyse data of their care are 97% and 88% respectively as per NSSO 75th round
customers to meet the needs of their core customers. The between July 2017-June 2018 [6]. However, the quality
other customers are also serviced but for short term, such component of the levels of anaemia and identification of
much more numerous other clients will probably generate Pregnancy induced hypertension are still in the range of 65-
more profits than right customers, as they do not have to put 70% and need to be improved. The promotion of Institutional
much effort to make that profit happen. Most of the corporate deliveries in the last decade country-wide has improved the
hospitals especially in major cities of India are investing in proportion of skilled birth attendance to the level 91.9 % in
such strategies i. Recognizing fundamental and inevitable rural and 96.5% in urban India. The institutional deliveries
differences among their customers ii. There is a quantifiable have reached a level of 90.5 % in rural and 96.1% in urban
value to be found in individual clients to focus on long term India, respectively. Only 8.1% in rural area and 3.4% in
marketing efforts iii. By working to quantify each customer urban areas are home deliveries attended by unskilled birth
they gain valuable insights as to how much they are willing to attendants. The proportion of caesarean sections stands high
spend to keep existing customer and to acquire new clients at 38.8% in Public sector facilities and 59.9% in private sector
iv. By doing this they serve better and in a personalized services that may need introspection and justification. An
manner than their competitors [12]. By following these average cost of normal childbirth in Indian Rupees was 3746
norms, the private health Industry is attracting lots of health (G=2084, P-12931) in rural and 8382 (G-2459, P-17960)
tourism and some of the institution makes more profit from in urban facilities. The caesarean section costed 20,200 (G-
international clientele. There is already growing concern 5423, P-29406) in rural and 28058 (G-5504, P-37508) in
about some of these facilities treating the local clients as Urban India [6].
other short-term beneficiaries and giving more importance
and better services to the foreigners. Neonatal and Infant Care

Essential Drugs Institutional deliveries, home based new-born care and

Sick new-born care units (SNCU) have improved the new-
Making quality medicines available at affordable born survival in the last 10 years. The neonatal mortality
prices for all, particularly the poor and disadvantaged, rate (NMR) declined from 52 per 1000 live births in 1990 to
through exclusive outlets called “Pradhan Mantri Bhartiya 28 per 1000 live births in 2013. At district level, while 9% of
Janaushadhi Kendras” is one of the best efforts made by India. the districts have already reached the NMR targeted in SDG3,
2,500 Jan Aushadhi stores will be opened in the country by nearly half (315 districts) are not likely to achieve the 2030
end of 2020 [17]. These Kendra’s sell most essential drugs target even if they realize the NMR reductions achieved by
for about 1/3 to half the cost of the branded drugs and their own states between the last two rounds of National
other supplies like sanitary pads (for INR 1). This initiative Family Health Survey of India [15]. That invites more efforts
gives us a hope that soon the out of pocket expenses for the in neonatal care and push for the India New-born Action
commonly used drugs and medical supplies will come down Plan (INAP) 2014. Full Immunization coverage among under
by half by 2030. 5-year-old children was in the range of 57%-62%. The
difference between urban (62.1%) and rural (58.4%) and
Way Forwards male (58.5%0 and female (60%) children was insignificant.
This situation is not encouraging as despite government’s
Based on personal experience of nearly 52 years in the efforts of intensive catch up immunization campaigns in
Indian Health system having seen the system from both the name of Indra-Dhanush and development partners like
Government side and development partners side the author UNICEF, WHO and UNDP, neither the coverage has reached
project that in best case scenario what India can achieve by desired 90% level nor the routine immunization has settled.
2030 by activities in the annexure 1. Immunization I fact has been consuming nearly 20-25% of
staff time at PHC level [16,17].
The first half a dozen of health services is being
implemented for over two decades now and are well Child and Adolescent Care
established. There is a scope to improve the outcomes in each
one of them and impinge on less time of the functionaries at While the growth and development of children is being
implementation level. monitored by the department of Women and Child welfare,
the nutritional situation of children is still a matter of
Pregnancy & Childbirth concern , although the prevalence of stunting among under-
five children decreased from 52% to 38% and underweight
Percentages of pregnant women receiving pre-natal care declined from 53% to 36% between 1992 and 2016,
and percentages of pregnant women receiving post-natal prevalence is still alarmingly high [18]. In 2016, India had

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 15 Journal of Quality in Health care & Economics

62 million stunted children, accounting for 40% of the global Pandemic, have taken both professional and population by
share of stunting. To address the childhood illnesses India surprise and have renewed the challenges before the public
had launched the Indian version of global IMCI called as health community. Public Health in India has showed that it
integrated management of neonatal and childhood illnesses was a whole-of-society’s approach to health that aimed at
(IMNCI) in 2003. By June 2010, it had been implemented in equitably to maximize the level and distribution of health and
223 of India’s 640 districts and more than 200 000 workers well-being focusing on people’s needs and preferences early
had been trained. Unfortunately, it was not pursued with the in the pandemic and ensuring the continuum from health
rigor it deserved and demanded. Intensive on-job support promotion and disease prevention efforts like, containment,
and logistic supply is still wanting. It is high time that the social distancing, hand wash, use of masks, cough etiquettes,
intervention gets its due importance. There are many toilet hygiene to treatment, rehabilitation and lockdown,
healthcare programs under various ministries to address the and as close as feasible to people’s everyday environment.
problems of adolescents, namely, Kishori Shakti Yojana, Balika Focus shifting to strengthening government health system
Samridhi Yojana, Rajiv Gandhi Scheme for Empowerment by creating dedicated facilities, procuring ventilators, PPEs,
of Adolescent Girls, “SABLA”, Rashtriya Kishor Swasthya and Rapid test kits, and strengthening laboratory services for
Karyakram, and Adolescent Reproductive Sexual Health PCR. Emergence of antibiotic-resistant strains of common
Programme (ARSH). Adolescent Health Programme as an organisms due to overuse of antibiotics and lack of vaccines
overarching Umbrella programme that covers all the health for many dangerous microorganisms poses problems to
interventions for children and youth, as pursued under NHM. humanity. This stresses the need for new vaccines, effective
The outcomes of these programs need to be evaluated and antibiotics and strengthened environmental control
requisite push given to achieve the full potential of all such measures. New knowledge of the microbiological origins
programs. of cancers such as that of the cervix, stomach and liver
have strengthened primary prevention and brought hope
Family Welfare & Reproductive Health Program that new cures will be found for other chronic diseases of
infectious origin. Tragically long delays in adopting “new”
Is one of the India’s oldest national program since 1951. and cost-effective vaccines cause hundreds of thousands of
In 2017, Ministry of Health and Family Welfare launched preventable deaths each year in developing and mid-level
“Mission Pariwar Vikas” a central family planning initiative. developed countries [18].
The key strategic focus of this initiative is on improving
access to contraceptives through delivering assured services, Management of IDSP
ensuring commodity security, and accelerating access to high
quality family planning services. India’s fertility rate as of Integrated disease surveillance Program was launched in
2016, was 2.3 births per woman and the program’s overall India in 2004 with the support of the World Bank and WHO.
goal is to reduce overall fertility rate to 2.1 by the year 2025. It is a decentralized laboratory-based IT enabled disease
Two contraceptive pills, MPA (Medroxyprogesterone acetate) surveillance system for epidemic prone diseases to monitor
and Chaya are being made freely available to all government disease trends and to detect and respond to outbreaks in
hospitals. Special focus in about 146 high fertility districts of early rising phase through trained Rapid Response Team
UP, MP, Bihar, Jharkhand, Chhattisgarh, Assam, and Rajasthan (RRTs). The concern of major hospital’s poor response to
should yield better outcomes. transmission of weekly surveillance reports (P&L forms)
continues, though all of them contribute a lot once there is an
Management of Communicable Diseases outbreak/epidemic or a pandemic. Routine reporting from
major hospitals may be made mandatory and monitored, as
Communicable disease is under the overall umbrella I feel we are missing many outbreaks in the initial stages for
of NHM. The past two decades have seen enormous want of reporting from OPD cases (both P& L forms).
achievements in control of infectious diseases, due to
sanitation and food safety, vaccines, antibiotics, and The expanded services are going to pose bigger
improved nutrition. Vaccination has eradicated smallpox, challenges to establish and give outcomes at least for next
eradicated poliomyelitis, and has greatly reduced Whooping 3-5 years.
cough, diphtheria, tetanus, and measles. Antibiotics have
helped in minimizing the damages of many tropical diseases, Daily OPD’s at HWCs
like malaria, tuberculosis, typhoid, Leprosy, Kala-Azar,
Filariasis etc, and made possible eradication of Guinea worm The health centres upgraded HWCs will encounter
disease. New diseases such as HIV and forms of influenza challenges in all aspects like infrastructure building, human
(H1N1, H5N1), Zika virus, Hanta virus and recently COVID 19 resource capacity building and drugs other supply logistics.

Suresh K. Fixing Sickness Care Component of Comprehensive Primary Health Care in India. J Qual Copyright© Suresh K.
Healthcare Eco 2020, 3(3): 000165.
 16 Journal of Quality in Health care & Economics

Most importantly making services available at convenient PIPs for CPHC

timings of the local population, based on seasonal farming
activities and gaining their trust of the population will The biggest challenge I visualize is the preparation of
demand not only quality services, good behaviour of the integrated CPHC plans for HWCs. So far neither Government
service providers and capacities of referral to the appropriate of India, any states have made any efforts in this direction.
referral institutions and their responses. This calls for a This is crucial in a large country where independent vertical
referral mechanism that has not been achieved in many programs have pulled and pushed the workers in different
vertical programs like TB, Diabetes, Asthma, IMNCI, NBC, directions periodically that confuse them so much that they
COPD etc. so far. The HWCs of present PHCs with medical can take shelter for not doing anything. The development
officers may be able to pull through most of the activities partners like WHO, UNICEF, UNFPA and UNDP may have
except mental health; Initial support by a Medical officer to take lead in this activity and create model plans for one
from nearest PHC on weekly basis will help on job skill and district in each state and in the process also build state
brand building. capacities for the same.

Screening, Prevention, Control, and Conclusion

Management of NCDS
Although there are major challenges ahead to meet the
Screening of Diabetes and Hypertension may be achieved ambitious goals of NHP 2017, it is important to capitalize
at least at PHC upgraded facilities, but screening for breast, on the current high level of political commitment accorded
cervical and oral cancers may fall short of achievement by to comprehensive primary health care4. If the all available
50%. resources are mobilized just like we are doing for addressing
current Pandemic of COVID 19, I am sure we will awfully
Care for Eye and ENT close to achieve the goals of majority of intentions.

These services may be just made available by end of References

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