Evaluating the role of Primary Health Centers in India

Neesha Patel

Globally, governments are searching for ways to improve equity, efficiency, effectiveness and responsiveness of their health systems. At present, there is no agreement on optimum structures, content, and ways to deliver cost-effective services to achieve health gains for the population. However, in recent years there has been an acceptance of the important role of primary healthcare in helping to achieve these aims; providing cost-effective healthcare to the general population. Primary healthcare is essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

International studies show that the strength of a country’s primary care system is associated with improved population health outcomes for all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from major respiratory and cardiovascular diseases. This relationship is significant after controlling for determinants of population health at the macro-level (GDP per capita, total physicians per one thousand population, percentage of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption).

In India, fertility, mortality and morbidity remain unacceptably high, both compared to countries in the region and those at similar income levels. Although poverty and low levels of education are the root causes, poor stewardship over the health system bears some responsibility. India’s primary healthcare system is based on the Primary Health Centre (PHC) which is not spared from issues such as the inability to detect diseases early due to lack of multi-disciplinary medical expertise and laboratory facilities and insufficient quantities of general medicines. At the same time, patients usually do not visit PHCs in the early stages of their diseases, while healthcare providers (if at all present) are forced to focus only on seriously ill patients due to the volume of cases.

What prompted me to write this article was a component of the speech given by Bill Gates at the 2005 World Health Assembly in Geneva. After an introduction based on the tragic health inequality between the developing and developed countries, the report addressed the importance of a fully-functioning healthcare delivery system; how millions of people could get the benefits of new discoveries if healthcare delivery was a priority and if delivery shaped design. Universal access to healthcare is a norm in most developed countries and some developing countries. Unfortunately, in India, not only is there pre-existing inequality in healthcare provisions, but this is further enhanced by difficulties in accessing it, which is due to geographical, socio-economic or gender distance.

Studies from developed countries demonstrate that an orientation towards a specialist-based system enforces inequity in access. Health systems in low income countries with a strong primary care orientation tend to be more pro-poor, equitable and accessible. At the operational level, the majority of studies comparing services that could be delivered as either primary health care or specialist services show that using primary care physicians reduces costs, and increases patient satisfaction with no adverse effects on quality of care or patient outcomes.

In India, Primary Health Centres (PHCs) are the cornerstone of rural healthcare; a first port of call for the sick and an effective referral system; in addition to being the main focus of social and economic development of the community. It forms the first level of contact and a link between individuals and the national health system; bringing healthcare delivery as close as possible to where people live and work.

Each PHC is targeted to cover a population of approximately 25,000 and is charged with providing promotive, preventive, curative and rehabilitative care. This implies offering a wide range of services such as health education, promotion of nutrition, basic sanitation, the provision of mother and child family welfare services, immunisation, disease control and appropriate treatment for illness and injury. The PHCs are hubs for 5-6 sub-centres that cover 3-4 villages and are operated by an Auxiliary Nurse Midwife (ANM). These facilities are a part of the three tier healthcare system; the PHCs act as referral centers for the Community Health Centres (CHCs), 30-bed hospitals and higher order public hospitals at the taluka and district levels.

Primary healthcare services substantially affects the general health of a population, however many factors undermine the quality and efficiency of primary healthcare services in developing countries. In India, although there are many reasons for poor PHC performance, almost all of them stem from weak stewardship of the sector, which produces a poor incentive framework. The World Health Organisation (WHO) specifically points out that to some extent, the deterioration in health status is attributed to inadequacies in PHC implementation, neglecting the wider factors that have been responsible for this deterioration such as lack of political commitment, inadequate allocation of financial resources to PHCs and stagnation of inter-sectoral strategies and community participation. The main ones being bureaucratic approach to healthcare provision, lack of accountability and responsiveness to the general public and incongruence between available funding and commitments.

The current PHC structure is extremely rigid, making it unable to respond effectively to local realities and needs. For instance, the number of ANMs per PHC is the same throughout the country despite the fact that some states have twice the fertility level of others. Moreover, political interference in the location of health facilities often results in an irrational distribution of PHCs and sub-centres. Government health departments are focused on implementing government norms, paying salaries, ensuring the minimum facilities are available rather than measuring health system performance or health outcomes. Further, the public health system is managed and overseen by District Health Officers. Although they are qualified doctors, they have barely any training in public health management; strengthening the capacity for public health management at the district and taluk level is crucial to improving public sector performance.

The lack of accountability stems from the fact that there is no formal feedback mechanism and incentive to treat citizens as clients. Patients often complain of rude and abrupt health workers that discriminate against women and minorities from scheduled castes or tribes. The lack of accountability leads to absentee doctors; as it is difficult to attract qualified doctors to rural areas, unresponsive ANMs, inconvenient opening times and little or no community participation.

The lack of resources, which is acute in some states, is certainly a contributing factor to the poor performance of the primary healthcare system. In poor states, spending levels are low while expectations for coverage remain high. The incongruence between resources and targets result in lack of medicines; the current budget for essential drugs being Rs 75,000 per annum which is insufficient to cater to large number of patients, limited doctor salaries. In order to improve primary care services, a number of approaches are used in developing countries. Capacity building and encouraging community involvement are some of the main factors. Capacity building aims to improve the knowledge and skills of primary care professionals and community involvement improves governance and accountability of public primary health clinics, which lead to increase in drug supply and improved provider skills. A widely used mechanism to improve primary health services is contracting.

Contracting improves public services by utilising the private sector’s greater flexibility to improve services and responsiveness to consumers, increases managerial autonomy, decentralizes decision making to managers on ground. It allows the government to focus less on service delivery and more on comparative advantage roles. Contracting can also improve the level of national equity as a government can create contracts that focus on delivering primary care services to vulnerable populations.

Improved access to primary healthcare and its gate-keeping function lead to less hospitalisation, less utilisation of specialist and emergency centres and less chance of patients being subjected to inappropriate health interventions. In low-income settings, the cost effectiveness of PHC compared to other health programmes has been reinforced by World Bank findings; selected primary healthcare activities such as infant and child health, nutrition programmes and immunisation appeared as ‘good buys’ compared to hospital care and such interventions could avert a large population of deaths. The Bamako Initiative in Benin and Guinea demonstrate that even in resource-poor settings, it is possible to implement and sustain basic PHC services.

Thus, it is evident that the success of health systems exists in tapping the existing potential and making appropriate structural changes. The role of primary care should not be defined in isolation but in relation to the constituents of the health system.

Primary, secondary, generalist and specialist care, all have important and inclusive roles in the healthcare system and should be used to create a comprehensive and integrated model; one that combines universalism and economic realism with the objective of providing coverage for all.