The document discusses India's primary health care system and proposes a model of Comprehensive Primary Health Care (CPHC) to achieve Universal Health Coverage. It outlines key challenges faced by the current primary health care system such as understaffing, supply issues, and over-reliance on private sector. The proposed CPHC model involves establishing "Health and Wellness Centers" at village level which will provide expanded services including management of non-communicable diseases. It emphasizes strengthening human resources, ensuring drug and diagnostic access, use of ICT, continuity of care, and community engagement to achieve the vision of comprehensive and affordable primary health care for all.

2.  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. 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. NHP 2017;
Astana
2018
SDG, FYP,
NHM
(2012)
NRHM
2005
NHP 2002MDG 2000NHP 1983HFA 2000
Alma
-Ata
1978
Bhore
1946

6.  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.  “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.  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

13.  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.  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.  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.  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)

19.  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.  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. NHP 2017;
Astana
2018
SDG, 12th
FYP, NHM
(2012)
NRHM
2005
NHP 2002MDG 2000NHP 1983HFA 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.  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.  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. 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. Health and
Wellness
Centres
(HWCs)
Sub-
centres
PHCs
Primary
Health
Care team

29.  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.  Population enumeration and empanelment of families
through active process
First
referral
level
HWC
Family/
community
level

32.  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.  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.  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

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

38.  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.  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.  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.  General population – primary prevention
 Population at risk
 Individual with symptoms
 Population with known disorders

42.  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.  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.  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.  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.  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.  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.  CPHC could reflect translation of policy
statement into budgetary commitments
 Budgetary allocation under National Health
Mission as part of state PIP
 Additional sources

49. 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.  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.  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.  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.  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.  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