Primary healthcare or local community level healthcare, similarly defined, is healthcare provided to all, especially the most marginalised, with their participation and for their needs. If the primary healthcare system of a country is not functioning well, it is symptomatic of problems in its democracy itself.

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Importance of local community level health care:

• Primary Health Care (PHC) is the heart and soul of medicine. It is the foundation of every health care system: the first contact and ongoing link between people and their health providers.
• PHC is how individuals and families connect with the health care system throughout their lives, for everything from prenatal checkups and routine immunizations to the treatment of illness and the management of chronic conditions.
• When PHC works, people are able to get the care they need to stay healthy. The vast majority of a community’s health needs can be met by a well-functioning primary care system.
• PHC explicitly ensures a focus on equity, accessibility and quality of care. PHC is people-focused: organized around people rather than diseases, and encompassing the full range of interventions that foster good health.
• The principles of the PHC approach of the Alma Ata declaration (1978) such as healthcare closest to home and appropriate technology that is effective, safe, cheap, and simple to use, need to be applied to the healthcare system as a whole. The PHC-infused-UHC could facilitate such a shift.

The major challenges faced by healthcare system in India are:

• Finance: At about 1.3% of the national income, India’s public healthcare spending between 2008 and 2015, has virtually remained stagnant. This is way less than the global average of 6 per cent. It is a herculean task to implement a scheme that could potentially cost Rs 5 lakh per person and benefit 53.7 crore out of India’s 121 crore citizenry, or roughly about 44% of the country’s population. Over 70 per cent of the total healthcare expenditure is accounted for by the private sector.
• Crumbling public health infrastructure: Given the country’s crumbling public healthcare infrastructure, most patients are forced to go to private clinics and hospitals. There is a shortage of PHCs (22%) and sub-health centres (20%), while only 7% sub-health centres and 12% primary health centres meet Indian Public Health Standards (IPHS) norms.
• High Out of Pocket Expenditure: Reports suggest that 70% of the medical spending is from the patient’s pockets leading to huge burden and pushing many into poverty. Most consumers complain of rising costs. Hundred days into the PMJAY, it remains to be seen if private hospitals provide knee replacement at Rs 80,000 (current charges Rs 3.5 lakh) bypass surgery at Rs 1.7 lakh (against Rs 4 lakh).
• Insurance: India has one of the lowest per capita healthcare expenditures in the world. Government contribution to insurance stands at roughly 32 percent, as opposed to 83.5 percent in the UK. The high out-of-pocket expenses in India stem from the fact that 76 percent of Indians do not have health insurance.
• Doctor-Density Ratio: The WHO reports the doctor-density ratio in India at 8 per 10,000 people as against one doctor for a population of 1,000.To achieve such access, merely increasing the number of primary and secondary healthcare centres is not enough.
• Shortage of Medical Personnel: Data by IndiaSpend show that there is a staggering shortage of medical and paramedical staff at all levels of care: 10,907 auxiliary nurse midwives and 3,673 doctors are needed at sub-health and primary health centres, while for community health centres the figure is 18,422 specialists.
• Rural-urban disparity: The rural healthcare infrastructure is three-tiered and includes a sub-center, primary health centre (PHC) and CHC. PHCs are short of more than 3,000 doctors, with the shortage up by 200 per cent over the last 10 years to 27,421. Private hospitals don’t have adequate presence in Tier-2 and Tier-3 cities and there is a trend towards super specialisation in Tier-1 cities.
• Social Inequality: The growth of health facilities has been highly imbalanced in India. Rural, hilly and remote areas of the country are under served while in urban areas and cities, health facility is well developed. The SC/ST and the poor people are far away from modern health service.
• Poor healthcare ranking: India ranks as low as 145th among 195 countries in healthcare quality and accessibility, behind even Bangladesh and Sri Lanka.
• Commercial motive: lack of transparency and unethical practices in the private sector.
• Lack of level playing field between the public and private hospitals: This has been a major concern as public hospitals would continue receiving budgetary support. This would dissuade the private players from actively participating in the scheme.
• Scheme flaws: The overall situation with the National Health Mission, India’s flagship programme in primary health care, continues to be dismal. The NHM’s share in the health budget fell from 73% in 2006 to 50% in 2019 in the absence of uniform and substantial increases in health spending by States.

Steps taken up currently:

• The National Health Policy (NHP) 2017 advocated allocating resources of up to two-thirds or more to primary care as it enunciated the goal of achieving “the highest possible level of good health and well-being, through a preventive and promotive healthcare orientation”.
• A 167% increase in allocation this year for the Pradhan Mantri Jan Arogya Yojana (PMJAY) — the insurance programme which aims to cover 10 crore poor families for hospitalisation expenses of up to ?5 lakh per family per annum.
• The government’s recent steps to incentivise the private sector to open hospitals in Tier II and Tier III cities.
• Individual states are adopting technology to support health-insurance schemes. For instance, Remedinet Technology (India’s first completely electronic cashless health insurance claims processing network) has been signed on as the technology partner for the Karnataka Government’s recently announced cashless health insurance schemes.

Measures needed to strengthen the existing state of Health infrastructure in the country are:

• There is an immediate need to increase the public spending to 2.5% of GDP, despite that being lower than global average of 5.4%.
• The achievement of a distress-free and comprehensive wellness system for all hinges on the performance of health and wellness centres as they will be instrumental in reducing the greater burden of out-of-pocket expenditure on health.
• There is a need to depart from the current trend of erratic and insufficient increases in health spending and make substantial and sustained investments in public health over the next decade.
• A National Health Regulatory and Development Framework needs to be made for improving the quality (for example registration of health practitioners), performance, equity, efficacy and accountability of healthcare delivery across the country.
• Increase the Public-Private Partnerships to increase the last-mile reach of healthcare.
• Generic drugs and Jan Aushadi Kendras should be increased to make medicines affordable and reduce the major component of Out of Pocket Expenditure.
• The government’s National Innovation Council, which is mandated to provide a platform for collaboration amongst healthcare domain experts, stakeholders and key participants, should encourage a culture of innovation in India and help develop policy on innovations that will focus on an Indian model for inclusive growth.
• India should take cue from other developing countries like Thailand to work towards providing Universal Health Coverage. UHC includes three components: Population coverage, disease coverage and cost coverage.
• Leveraging the benefits of Information Technology like computer and mobile-phone based e-health and m-health initiatives to improve quality of healthcare service delivery. Start-ups are investing in healthcare sector from process automation to diagnostics to low-cost innovations. Policy and regulatory support should be provided to make healthcare accessible and affordable.

Conclusion:

India needs a holistic approach to tackle problems in healthcare industry. This includes the active collaboration of all stakeholders public, private sectors, and individuals. Amore dynamic and pro-active approach is needed to handle the dual disease burden. A universal access to health makes the nation fit and healthy, aiding better to achieve the demographic dividend.