This document outlines key aspects of comprehensive primary health care (CPHC) in India to achieve universal health coverage. It discusses the evolution of primary health care from 1946 to present day initiatives. The proposed CPHC model includes establishing health and wellness centers, a national health protection scheme, and addressing human resources, continuity of care, access to drugs/diagnostics, and community linkages through a strengthened primary health care system. The document highlights achievements but also ongoing challenges to equitable access and improving health outcomes across India.

1. A package of Quality Essential
Health Care Services in India

2. Objectives
To highlight heterogeneity of health care system in
India
To define and describe evolution of primary health
care in India
Key achievements and challenges to primary health
care
Proposed model of Comprehensive Primary Health
Care (CPHC) to achieve Universal Health Coverage
(UHC) and financial risk protection
Key challenges to CPHC

3. Quality Essential Health care services
Preventive Curative
Primary Tertiary
Community-based Speciality based
ASHA Super specialists
Public Private

4. Health Care System
Village
Village level
workers
Sub-centres
PHC
CHC
Hospitals
Sub-
divisional
Hospitals
District
Hospitals
Regional
Hospitals
Specialist
and teaching
Hospitals
Private
providers
Indigenous
system of
Medicine
Informal
providers
International
Health
Agencies

5. Primary Health Care……
NHP
2017;
Astana
2018
SDG,
FYP,
NHM
(2012)
NRHM
2005
NHP
2002
MDG
2000
NHP
1983
HFA
2000
Alma-
Ata
1978
Bhore
1946

6. Comprehensive Health Care
(Bhore 1946)
 Provide adequate preventive, curative and promotive health
services
 As close to the beneficiaries possible
 Has widest co-operation between people, service and profession
 Available to all irrespective of their ability to pay
 Look after specifically the vulnerable and weaker sections of the
community
 Create and maintain healthy environment

7. Primary health care
(Alma-Ata conference 1978)
 “Essential health 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 country can afford to
maintain at every stage of their development in the spirit of self-determination”
 Include at least:
 Education about prevailing health problems and methods of preventing and controlling them
 Promotion of food supply and nutrition
 Adequate supply of safe water and basic sanitation
 Maternal and child health care including family planning
 Immunization
 Prevention and control of infectious diseases
 Appropriate treatment of common diseases and injuries
 Provision of essential drugs

8. Why Primary Health Care?
 First level of contact with professional care; interface between self
care and secondary and tertiary facilities
 Platform to provide preventive, promotive and curative services; not
restricted to few important problems
 Reduces morbidity and mortality at lower cost and reduces need for
secondary and tertiary care
 Better health outcomes at lower expenditure
 Address equity

9.  National Health Policy 1983
 To achieve Health for ALL by universal provision of primary health care services
 Small family norm
 Reorientation of Medical and Health education to meet national priorities
 Restructuring existing govt health organizations for comprehensive primary health
care and public health services with integrated referral services
 Indigenous and other systems of health care
 Nutrition and prevention of food adulteration and quality of drugs
 Water supply, sanitation and environmental protection
 Immunization programmes
 Maternal and child health services
 School health programmes
 Occupational health services
 Health education
 Inter sectoral cooperation

10. Indicator
Goal 1 : Eradicate extreme poverty and hunger
target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger
Indicator 14: Prevalence of underweight children (less than 5 years of age)
Indicator 15: Proportion of population below minimum level of dietary energy consumption
Goal 4: Reduce child mortality
Target 5: Reduce by 2/3rd the under-5 mortality rate
Indicator 13: Under five mortality rate
Indicator 14: Infant mortality rate
Indicator 15: Proportion of 1 year old children immunized for measles
Goal 5: Improve maternal health
Target 6: Reduce maternal mortality ration by 3/4th
Indicator 16: MMR
Indicator 17: % of births attended by skilled health personnel
Target B
Contraceptive prevalence rate, Adolescent birth rate, Antenatal care coverage (3 or more), Unmet
need for family planning
Millennium Development Goals (MDG)

11. Goal 6: Combat HIV/AIDS, Malaria and other diseases
Target 7: Have halted and begun to reverse the spread of HIV/AIDS
I 18: HIV prevalence among young people 15-24 years, 15-49 years, Pregnant women aged 25-49 years
I 19 (a): Condom use rate among non-regular sex partners
I 19 (b): % of population aged 15-49 years with comprehensive correct knowledge of HIV/AIDS
Target 8: Have halted and begun to reverse the incidence of Malaria and other major diseases
I 21: API, No. of confirmed deaths due to Malaria per 1 lakh population
I 22: No. and % of people with fever given presumptive treatment, no. and % of people with malaria given
radical treatment, % of villages with DDC, FTD, % of targeted population in high risk area covered with IRS,
% of ITN distributed against targeted population
I 23: TB incidence rate per 100000, TB death rate per 100000
I 24: % of SP TB cases detected and put on DOTS, % of SP TB cases cured under DOTS
Goal 7: Ensure environmental sustainability
Target 9: Integrate principles of sustainable development in country policies and reverse loss of env resources
I 29: % of population using biomass fuels
Target 10: Halve % of people without access to safe drinking water
I 30: % population with access to an improved water source, rural and urban
Target 11: BY 2020 significant improvement in lives of atleast 100 million slum dwellers
I 31: % of urban population with access to improved sanitation
Goal 8: Develop global partnership for development
Target 17: Provide access to affordable essential drugs in developing countries
I 46: % of population with access to affordable essential drugs on sustainable basis through govt health facilities

12. National Health Policy-2002

13. National Rural Health Mission (NRHM)
 Launched 12th April 2005
 To provide affordable, accessible, accountable, effective and
reliable primary care to those who need most
 Accredited Social Health Activist (ASHA)
 Strengthening of SC, PHC and CHC
 Decentralized planning and integration of vertical programs
 Community involvement mechanism; VHSNC, RKS, ASHA
 Mainstreaming of AYUSH

14. Key achievements
 MDG goals of MMR (556 vs 130) and U5 MR (126 vs 42) achieved
 % of underweight children decreased to 29.4% form 52% in 1990
 11 of 20 large state have achieved TFR of 2.1 or below
 Elimination of Poliomyelitis and Neonatal tetanus
 Elimination target of Leprosy (PR<1 per 10,000) achieved
 Reduced HIV prevalence (041% in 2001 to 0.27% in 2011)
 Significant decline in Malaria morbidity and mortality
 Free and universal accessibility to ART, AKT, RDT, MDT, immunization and
much of MCH services
 9,00,000 ASHA and 1,78,000 health workers added
 Cash transfer to 10 million pregnant women annually for institutional care
 Rashtriya Swasthya Bima Yojna (RSBY)

15. Still a long way to go….
 Infant, Neonatal mortality and still birth rates are still high with
high wide geographical and social disparities
 Major contributor states have not achieved TFR of 2.1
 About 1/3rd under-five children are malnourished (NFHS-4)
 More than half of under-five children, adolescent girls and
pregnant and non-pregnant women are anaemic (NFHS-4)
 Vector-born disease such as dengue, chikungunya and viral
encephalitis are on rise
 Challenges in TB, Malaria and HIV

16. Still a long way to go…
Structural Constraints (RHS 2018)
Understaffing of front-line workers and professionals
About 1/3rd posts of qualified allopathic doctors, and 90% of specialist are
vacant
About 10% of Pharmacists, laboratory technicians, auxiliary nurse midwives
(ANMs) and male health workers are vacant
>1/3rd male and female supervisors post are vacant in Gujarat
Support services such as X ray facilities are hampered with >2/3rd radiographer
positions vacant
Role of Community health volunteers
Lack of incentives and poor career advancement  poor performance

17.  Lack of acceptance of relevant standards
 Supply side deficiencies
Infrastructure, drugs, logistics and equipment
 Oversimplification of Primary health care
Only deal with ‘priority’ problems; non-responsive to ‘felt’ needs of
community
One-way delivery of priority interventions; patient-provider relationship
Stand alone post or isolated health worker; fragmented health care
delivery
Low-tech non-professional care without specialized support
Limited attention to social determinants
Lack of community participation

18. Mismatch between provider training and
performance
Inequity in access to health services and health
outcomes
Concerns about quality of care
Unrealized potential of Information communication
technology (ICT)
Still a long way to go…..

19. Still a long way to go…..
 Inadequate utilization (NSSO 2014)
11.5% of rural and 4% of urban households have reported seeking out-
patient care from primary care facilities (except for childbirth) for
common ailments
75% of outpatient and 62% of inpatient care is provided by private
sector
 High out of pocket expenditure
High reliance on private sector, along with low coverage of health
insurance, have resulted in high out-of-pocket expenditure (69.1% of
total health expenditure),
10% increase in household facing catastrophic healthcare expenditures
Average out-of-pocket expenditure for delivery in public health facility is
Rs 3197 (NFHS-4)

20. Inadequate financing
Inadequate public health insurance
Still a long way to go…..

21. Added challenges…
 Epidemiological transition
Non-communicable diseases (60%), injuries (12%) and mental
illnesses
 Demographic transition
Growing need of geriatric health services and palliative care
 Social determinants of health
Life style factors, environmental factors, substance abuse,
nutrition, gender-based violence, health system factors
Demand Inter-sectoral action
 Urban Health

22. Primary Health Care……
NHP
2017;
Astana
2018
SDG,
12th FYP,
NHM
(2012)
NRHM
2005
NHP
2002
MDG
2000
NHP
1983
HFA
2000
Alma-
Ata
1978
Bhore
1946

23. By 2030 reduce MMR to less than 70 per 100000 live births Achieve universal health coverage
By 2030, end preventable deaths of new-borns and children under 5
with NMR 12/1000 live births and under-5 mortality to as low as 25 per
1000 live births
By 2030 reduce deaths and illness from hazardous chemicals and
air, water and soil pollution
By 2030 end epidemic of AIDS, TB, Malaria and neglected tropical
diseases and combat Hepatitis, water-borne disease and other
communicable diseases
Strengthen implementation of WHO FCTC
By 2030 reduce premature mortality from NCDs by 1/3rd by prevention
and treatment and promote mental health and well being
Support research and development of vaccines and medicines for
communicable and NCDs, access to vaccines and essential
medicines
Strengthen prevention and treatment of substance abuse including
drugs and alcohol
Increase health financing and recruitment, development, training and
retention of health workforce in developing countries
By 2020, halve no. of deaths and injuries from RTA Strengthen capacity for early warning, risk reduction and
management of national and global health risks
By 2030, universal access to sexual and RT services, family planning,
IEC, integration of Reproductive health in national programmes
Sustainable development goals (SDG) 2016-30
Goal 3: Ensure healthy lives and promoting well-being for all at all ages – 13 targets

24. National Health Policy -2017
 Universal access to quality health care services at affordable cost
 Increase public expenditure to 2.5% of GDP with 2/3rd for primary
health care
 Package of comprehensive primary health care through ‘Health
and Wellness centres’ – NCD, geriatric, mental health, palliative
and rehabilitative care
 Free drugs, diagnostics, essential and emergency health care in all
public hospitals
 Standards of quality of health care
 Make in India and Medical education reform
 Mid level service providers, public health cadre, nurse
practitioners

25.  ‘Health is the fundamental human right’
 ‘Primary Health Care is the most inclusive, effective and efficient approach
to universal health coverage (UHC) and SDG’
 ‘We will continue to address the growing burden of NCDs’
 ‘Preventive, promotive, curative, rehabilitative and palliative care must be
accessible to all’
 ‘We must save millions of people from poverty due to disproportionate out-
of-pocket spending on health
 ‘We will strive for retention and availability of the PHC workforce in rural,
remote and les developed areas’
 ‘Health in All’
 Build sustainable primary health care

26. Comprehensive Primary Health Care
(CPHC)
Major constraint of Primary Health Care
Under funded
Selective health care package
Lack of financial protection
Health and Wellness Centres (HWCs)
National Health protection scheme (NHPS)

27. Core components of CPHC
CPHC
Institution
structure and
service
organization
Human
resource
policy
Access to
drugs and
diagnostics
ICT
Continuity
of care
Social
determinants
of Health
Community
linkages and
social
mobilization
Quality
of care
Governance,
Financing

28. 1. Institutional structures and
Organization of services
Health and
Wellness
Centres
(HWCs)
Sub-
centres
PHCs
Primary
Health Care
team

29. Planning, location and infrastructure
upgrade of HWCs
Ensure equitable distribution (travel time to care) and
optimal utilization of resources
Incremental approach
Addressing gaps in infrastructure and manpower
jointly by health and engineering departments in
consultation with Primary health care team and
community

30. Health and
Wellness
Centres
(HWCs)
Expanded range of services
1. Care in pregnancy and child-birth
2. Neonatal and infant healthcare services
3. Childhood and adolescent health care
4. Family planning, contraceptive and other RCH
services
5. Management of Communicable diseases and NHP
6. Management of CDs and outpatient care for acute
simple ailments
7. Screening, prevention, control and management of
NCDs
8. Care for common ENT and Eye problems
9. Basic oral health care
10. Elderly and palliative health care services
11. Emergency medical services
12. Screening and basic management of mental health
services

31. Organization of services
 Population enumeration and empanelment of families through
active process
First referral
level
HWC
Family/
community
level

32. 2. Continuity of Care
 From Facility to home and across levels of care
 Requires
Development of referral linkages
Ensuring two-way referrals between various facility levels
 At Community/household level
 At HWC level
 Higher facility level

33. 3. Human resource policy
 Mid level health provider
 Role of MLHP
Public health functions, ambulatory care, management and
leadership
Coordinate with community platforms and address social
determinants of health
 Multi-skilling of other frontline health workers
 Capacity building of Primary health care team
 Career progression of MLHP

34. 4. Access to drugs and diagnostics
 Essential for Credibility and continuum of care
 Avoid patient hardships and compliance
 Address supply side issues
 Essential drug list, IPHS and Free diagnosis initiative of states
would serve as guiding documents
 Utilization guided by Standard treatment guidelines and
standard care pathways
 Robust system of procurement, supply linked with real-time
utilization

35. Indicative list of
diagnostics in CPHC

36. Indicative list of screening methods under
CPHC

37. Central
Diagnostic
unit
(CDU)
HWC
HWC
HWC HWC
HWC
HWC

38. 5. Information and Communication
Technology (ICT)
 Key functions
 Registration
 Service delivery
 Generate work-plans for teams with alert and reminder feature
 Validation of service use and cash assistance
 Capture service coverage and outcomes
 Generate and transfer records and reports for routing monitoring,
performance appraisal and teleconsultation
 Inventory management
 Capacity building
 Reduce burden of data recording and reporting and time-saving
 Potential for paperless system

39. Key issues
 Ability to manage large data volumes
 Security and data privacy
 Adaptive in nature
 Integration with state level MIS, RCH other programme
systems
 Offline mode function
 Auto-upgradation of additional technical support
 IT support team

40. 6. Health promotion, community mobilization
and social determinants of health
Priority areas
Cleanliness and sanitation
Balanced, healthy diets and regular exercise
Substance abuse
Injurie and accidents
Gender violence
Stress and workplace safety
Indoor and outdoor air pollution
 Incorporation of YOGA and Ayurveda clinics
 Innovations

41. Target groups
General population – primary prevention
Population at risk
Individual with symptoms
Population with known disorders

42. Agents of change
Mid level Health Provider
Coordination and provision of health promotion activities at
HWC and community level and ensuring equity
ASHA
Improving access to care
Undertake and support health promotion activities
Service provision

43. Agents of change
 VHSNC, Mahila Arogya Samitis, Self-help groups
 Facilitate inter-sectoral convergence, local planning and action to
address access and quality of care
 Engage women groups to ensure gender equity in women health
 Capacity building of PRI in community level planning, action and
monitoring to address social determinants of health
 Demand generation of CPHC services through focused IEC
 Building awareness about various government financial risk protection
schemes
 Patient support groups
 Health and Wellness Ambassadors
 School teachers (2 per school)

44. Inter-sectoral convergence
 Maternal and child health (ICDS, Education)
 Nutrition (ICDS, education, food and drug)
 Vector control and sanitation (rural development, urban
bodies, PRI)
 Better cooking practices in Mid-day meal program (education)
 Environmental protection (rural development, urban bodies,
PRI)

45. 7. Quality of care
 Mere availability is not enough
 Patient-centred and respectful
 Patient amenities at HWC
 Adherence to STG and clinical protocols
 To achieve Indian Public Health Standards (IPHS)
 Implementation of National Quality Assurance Standards for
public health facilities
A. Service provision, B. Patient right, C. Inputs, D. Support
services, E. Clinical services, F. Infection control, G. Quality
management, H. Health outcomes

46. Quality of care
 Kayakalp, Swachchhata audit, LaQshya, WASH
 Infection control measures,
 Bio-medical waste management and linked to CBMWTF
 Statutory licences and authorization
 Patient satisfaction surveys
 Performance linked payments
 Team incetives

47. Issues while ensuring quality
Availability of quality standards doesn’t translate into
outcomes
Provider competency, behaviour, attitude and efforts
are critical to deliver quality services and fill ‘know-
do’ gaps
Capacity building, supportive supervision and
feedback

48. 8. Financing
CPHC could reflect translation of policy statement
into budgetary commitments
Budgetary allocation under National Health Mission
as part of state PIP
Additional sources

49. 9. Governance &
Monitoring
NHM division, MOHFW and
NHSRC as technical support
Mission Director NHM
Director/addnl./joint director
supported by all Program officers
and team of consultants; SHSRC to
technical support
CDHO/dedicated program officer
supported by DPMU staff
Block Medical officer supported
by BPMU

50. Monitoring
 Program management team at various levels
 Use of IT platform for monitoring of program related indicators
 Independent monitoring
 Existing grievance redressal mechanism and Helpline
 Community-based monitoring and Social accountability
VHSNC, RKS, Community Action for Health

51. National Health protection scheme (NHPS)
 Offset dire strait access to specialized services among rural and
urban poor
 Health insurance cover of up to Rs. 5,00,000 per family per year on
floater basis
 Envisages to provide financial protection from catastrophic health
expenses to 10.74 crore rural and urban poor families
 Cover almost all secondary and majority tertiary care procedures
through network of government and empanelled private hospitals
 Without any cap on family size or age
 Cover all pre-existing disease

52. Challenges to CPHC in India
 Political commitment and sustainability
 Shortage of manpower at all levels of care due to various reasons
 Existing infrastructure of many PHC and SC is highly inadequate to
function as HWCs
 Difficulties in meeting population norms of HWCs
 Deviation from primary objectives of front line workers due to
diversification and multi-skilling
 Intervention hotchpotch at HWCs!
 CHC are not providing services envisaged under HWCs!!!
 Mismatch between referral setup and HWC needs
 Equity is difficult to address!!!
 Social determinants of health and inter-sectoral convergence
Source: Bakshi H, Sharma H, Kumar P, Indian J Community Medicine, 2108; 43(2): 63-66

53. Critical areas under NHPS
 Sustainability of financial outlay
 Willingness of states to implement scheme
 State-specific health insurance schemes
 Weak secondary/tertiary care in public facilities push patient to
urban private sectors and results in out-of-pocket expenditure
(OOPE)
 Overreliance on for-profit sector and its consequences; government
becomes financer from provider
 Strategic purchasing not possible at this time!
 Outpatient care is major contributor in OOPE; not covered under
NPHS
 Is National Health Protection Scheme a misnomer!!!?
Bakshi H, Sharma H, Kumar P Indian J Community Medicine, 2108; 43(2): 63-66

54. To summarize…
 Comprehensive primary health care augmented with
National health protection scheme has potential to achieve
Universal Health Coverage and financial risk protection
 Constraints related to infrastructure, manpower and logistics
need to be addressed quickly
 Strengthening of referral system at secondary and tertiary
level
 Sustained political and financial support
 Prioritizing social determinants of health

55. THANK YOU