The importance of primary care in rural healthcare systems

Primary care serves as the first point of contact between individuals and the healthcare system, offering a spectrum of services aimed at promoting health, preventing diseases, and managing common health issues. Secondary and tertiary care refer to increasing levels of speciality and complexity in health care. According to the World Bank almost 90 per cent of all health needs can be met at the primary health care level. Consequently, primary healthcare is essential to achieving Universal Healthcare and Sustainable Development Goal (SDG) 3 – ‘Good Health and Well-being’. Research has concluded that effective primary care enables improved health outcomes and lower costs (1) and it is associated with lower rates of avoidable admissions to hospital and fewer potential years of life lost (2). Primary Healthcare is rooted in a commitment to social justice, equity, solidarity and participation. It is the most inclusive, equitable, cost-effective and efficient approach to enhance people’s physical and mental health, as well as social well-being (3).

But, unfortunately, 50 per cent of the world’s population lacks access to quality primary healthcare services. India ranks poorly in terms of quality and accessibility of primary healthcare. It is also experiencing a demographic as well as an epidemiological transition. The population faces a dual disease burden – rates of NCDs are rising rapidly while health systems are still trying to manage the burden of communicable diseases. The public health expenditure in India has historically remained less than 1.5 per cent of GDP, far less than the world average of 6 per cent.

In rural India, the primary care architecture consists of a tiered network of Sub-Centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs). An estimated 32 per cent of the rural population does not have access to OPD facilities. With a 22 per cent shortage of PHCs and 32 per cent shortage of CHCs, it is estimated that 50 per cent of beneficiaries travel more than 100 km to access quality care (4) . The public healthcare system lacks adequate infrastructure, doctors & trained workers, with massive absenteeism. Almost 75 per cent of dispensaries, 60 per cent of hospitals and 80 per cent doctors are in urban areas. This results in more than 70 per cent of the population relying on the private health care system that is fragmented and unorganised. Often rural poor, who value convenience and affordability, turn to unqualified medical practitioners even at the risk of adverse health outcomes. 

High consumer demand, incentives structure in the medical profession and the medico-industrial complex tilts resource flow towards specialised hospital care to the detriment of investment in primary care. Private sector has attempted and failed at creating a viable primary care model – Sugha Vazhvu, Razi Clinics, NationWide, WhiteCross are just a few names out of hundreds of attempts. International experience of building strong primary care system (Thailand and Brazil) also suggests that the government has to play the dominant role. 

Inspired by the National Health Policy, 2017, Ayushman Bharat a national initiative was launched by the Government of India to achieve universal healthcare. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) provides a cover of Rs 5 lakh per family per year for hospitalisations to 40 per cent of the poorest and vulnerable population. However, as much as 80 percent of out-of-pocket expenditure is due to out-patient care costs that are not covered under the scheme. The other component of Ayushman Bharat aimed at creating 1.5 lakh Health and Wellness Centers (HWC) for providing comprehensive primary care to the people. Most PHCs and many SCs were converted into HWCs now rebranded as “Ayushman Bharat Aarogya Mandirs.”

As per independent research, 70 per cent of OPD cases do not require in person visit and a much smaller number require hospitalisation. It will be very difficult, if not impossible to bring doctors and specialists to rural areas. A good digital healthcare solution can take care of the majority of the community’s needs and also unclog hospitals to serve patients who truly need hospitalisation. It has the potential to improve access and drive down cost dramatically, making it viable to deliver healthcare in remote areas. A hybrid assisted digital health model will work best in India due to limited capacities and the existing health seeking behaviour. The COVID-19 pandemic has helped accelerate digital health adoption. The government launched the e-Sanjeevani platform for teleconsultations with existing doctors in public health. The government has also finalised the guidelines for enabling Telemedicine services in HWCs.

The targeted HWCs have been set up across rural India and the e-Sanjeevani platform has been rolled out. However, they did nothing to improve availability of doctors, diagnostic tests or specialists for managing NCDs in rural areas. It is here that Public Private Partnerships have been transformational. Several states like Andhra Pradesh, Odisha, Jharkhand, Madhya Pradesh have partnered with private sector players like Glocal Healthcare, Apollo and eVaidya to ensure availability of doctors digitally through Telemedicine and point of care diagnostics at the Health and Wellness Centres. In this model the Telemedicine Centre is operated by a Nurse or paramedic, who registers the patient, takes the vitals and connects digitally to doctors based in the comforts of big cities for a video consultation. On the doctor’s advice the operator does diagnostic tests and finally dispenses medicines as per prescription. The model is now implemented at scale. NHM, Madhya Pradesh is using Telemedicine under PPP to fulfil the need for specialist doctors at all its 1,200 rural PHCs. This is a viable primary care model for rural India. It should be replicated by every state. 

Use of Clinical Decision Support Systems, Artificial Intelligence and advanced point of care diagnostics will make it more comprehensive, improve access, effectiveness, affordability and avoid medical errors. A strong primary care system is patient-centred, comprehensive and allows for the integration of all health services, benefiting communities and improving health outcomes for all. Such a model has the potential to transform primary healthcare across the globe, not just rural areas of India.

References:

1.  Starfield et al, 2005; Atun, 2004
2.  Kringos and others, 2013
3.  WHO
4. PwC, 2017, Funding Indian healthcare: Catalysing the next wave of growth