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Chapter # 28. Comprehensive Primary Health Care

Objectives 

Under Ayushman Bharat, scale-up a new vision for comprehensive primary health care across the country, built on the platform of health and wellness centres (HWCs), to:

  • Provide quality ambulatory services for an inclusive package of diagnostic, curative, rehabilitative and palliative care, close to the people.
  • Deliver preventive and promotion services, and action on the ground to tackle determinants of ill health locally.
  • Create a mass movement for Healthy India (Swasth Bharat Jan Andolan).

Current Situation

Primary health care is a key enabler for higher life expectancy, better health outcomes and lower costs for the nation. Primary health interventions help detect diseases early, well before complications set in, thus pre-empting the need for secondary and tertiary care.

Developed nations such as the UK, Australia, Canada, Netherlands and Sweden spend a large share of their federal healthcare budgets on primary care.1 In India, primary care infrastructure exists as a network of sub-centres, primary health centres and community health centres.

However, the focus of services has remained narrow – largely prioritized around reproductive, maternal and child healthcare, and some communicable diseases (notably, malaria). The battle against non-communicable diseases can only be won through a primary health system that ensures that chronic diseases are not only detected early, but also that preventive action is taken to ensure improved lifestyles.

The National Health Policy (NHP), 2017, envisages comprehensive primary health care delivered through HWCs. The policy also commits that two-thirds or more of government spending will be targeted at primary care. Additionally, the announcement of Ayushman Bharat by the government is a game changer.

Constraints

  1. The existing primary health care model in the country is limited in scope. Even where there is a well-functioning public primary health centre, only services related to pregnancy care, limited childcare and certain services related to national health programmes are provided, which represent only 15 per cent of all morbidities for which people seek care.2
  1. The conversion of 150,000 sub centres into HWCs was announced in the budget speech in 2017 and was enshrined in the NHP, 2017. Although less than 4000 such centres were sanctioned in 2017-18, the government is committed to accelerating the pace of sanctioning and putting up HWCs to meet the target in good time.
  1. Supply side deficiencies, poor management skills and lack of appropriate training and supportive supervision for health workers prevent delivery of the desired quality of health services.
  1. A primary health care model for the growing urban population has not been conceptualized, notwithstanding a few assorted initiatives by some states.
  1. Although the National Health Mission focuses on engaging communities through village health, nutrition and sanitation societies, health has not yet become a people’s movement.
  1. Funding for health is inadequate, leading to low spending on primary care.
  1. Citizens have to incur high out-of-pocket expenditure on primary health care, of which the largest expenditure is on drugs.
  1. There is a shortage of adequately trained and motivated personnel.

Way Forward

  1. Accelerate the establishment of a network of 150,000 HWCs
  • Operationalize a network of 150,000 HWCs on priority by 2022-23 in order to ensure sufficient coverage of affordable primary care and lower the burden on secondary and tertiary care.
  • HWCs should provide services such as screening and management of non-communicable diseases; screening and basic management of mental health ailments; care for common ophthalmic and ENT problems; basic dental health care; geriatric and palliative health care, and trauma care and emergency care.
  • These are in addition to the existing requirement for primary care services related to reproductive and child health, adolescent health, and selected communicable diseases covered by national health programmes.
  • The key features of New India’s primary health care system will be:

o A primary health care nucleus comprising five to six upgraded sub-centres coupled with a primary health centre, and population outreach.

o A team led by a mid-level health service provider,3 auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs) and a male health worker responsible for comprehensive primary health care services for a population of about 5,000.

  • Planning of health facility distribution in districts to ensure that a continuum of care is available on the principles of ‘time to care’ through a strong referral linkage.
  • Digitization of family records and information from the community to the facility level.
  • Use of real-time data to guide public health action and implementation monitoring.
  • The HWCs would act as the ‘gateway’ for access to secondary and tertiary health services.
  1. Enable mechanisms for rapid scale up
  • Put in place the following work streams to create 150,000 well-functioning HWCs across the country – infrastructure; human resources (mid-level professional recruitment, training and deployment; deployment and orientation of ANMs and male health workers); an Infor-mation and Communication Technology (ICT) system; supply chain for drugs and disposables; clinical and public health protocols and tools; managerial/supervisory processes, and monitor-ing, evaluation and accountability systems.
  • Under Ayushman Bharat, put in place the necessary institutional mechanisms with a focus on health and wellness at the central and state levels for effective, timely and robust system level implementation as well as strong engagement with departments/directorates of health in the states.
  • Establish special national and state level task forces and ‘command centres’.
  • Create mechanisms for rapid scaling up of training.
  • Develop empowered governance mechanisms for efficient decision-making, coordination, funds flow, procurement, contracting, recruitment, construction and implementation.
  • Mobilize Corporate Social Responsibility (CSR) and Non-Resident Indians for funding HWCs.
  • Some HWCs could also be mobile, particularly for better access to remote communities.
  1. Coordinate action for disease prevention and public health promotion and to address social determinants of health
  • Provide preventive services to improve healthy behaviours for family health and control the incidence of communicable and non-communicable diseases among the population covered by HWCs.
  • Facilitate partnerships between HWC teams and other frontline development teams (nutrition, education, Swachh Bharat) to engage with communities to address the socio-cultural and environmental determinants of ill health at the local level.
  1. Catalyse people’s participation for healthy India: Swasth Bharat Jan Andolan
  • Mandate and motivate HWC teams to work closely with village health, sanitation and nutrition societies, panchayati raj institutions as well as all other constituents of civil society in rural and urban spaces. This is vital because people are not just targets of health services but partners and multipliers of health-related activities.
  1. Emphasise concurrent learning, operations research and innovation
  • Undertake a well-funded research programme to find the best pathways for effective and context-specific scaling up of primary health care. This is critical because it is well-known that a single model of primary health care may not work for all districts/states in the country.
  • Conduct research to assess the population-level health impact of the programme and effects on out-of-pocket expenses.
  • Develop urban adaptations of comprehensive primary care.



Chapter # 41. Data Led Governance and Policy Making

Objectives Evidence based policy making should be made integral to the overall governance structure in New India, 2022-23. To achieve this, timely gen

Chapter # 40. Optimizing the Use of Land Resources

Optimizing the Use of Land Resources-Ensuring that land markets function smoothly, through efficient allocation of land across uses, provision of secu

Chapter # 39. Modernizing City Governance For Urban Transformation

Objective  City Governance For Urban Transformation To transform our cities into economically vibrant and environmentally sustainable habitats that p

Chapter # 38. Civil Services Reforms

Objective  civil-services-reforms To put in place a reformed system of recruitment, training and performance evaluation of the civil service to ensur

Chapter # 37. Legal, Judicial and Police Reforms

Objective To ensure the safety and security of citizens and ensure access to effective legal systems and speedy delivery of justice. Current Situation

Chapter # 36. The North-East Region

Objectives The North-East Region (NER) should: Have adequate road, rail and air connectivity, waterways, internet connectivity and financial inclusion

Chapter # 35. Balanced Regional Development: Transforming Aspirational Districts

Objective  Balanced Regional Development: Transforming Aspirational Districts Achieve balanced development in India by uplifting 115 districts, curre

Chapter # 34. Scheduled Castes (SCs), Scheduled Tribes (STs), Other Backward Classes (OBCs), Other Tribal Groups and Minorities

SCs, STs, OBCs, De-Notified Tribes (DNTs), Nomadic Tribes (NTs) and Semi-Nomadic Tribes (SNTs) Objective  To accelerate the socio-economic developm

Chapter # 33. Senior Citizens, Persons with Disability and Transgender Persons

SENIOR CITIZENS  Objective To ensure a life of dignity, social security and safety for senior citizens, enabling them to actively participate in econ

Chapter # 32. Gender

Objective  To create an enabling environment, sans institutional and structural barriers. To enhance the female labour force participation rate to at

Chapter # 31. Nutrition

Objectives  Under POSHAN Abhiyaan, achieve the following outcomes by 2022-23, compared to the baseline of 2015-16 (National Family Health Survey-4):

Chapter # 30. Universal Health Coverage

Objectives  On the strong platform of Pradhan Mantri – Jan Arogya Yojana (PM-JAY): Attain a coverage of at least 75 per cent of the population

Chapter # 29. Human Resources for Health

Objectives  Achieve a doctor-population ratio of at least 1:1400 (WHO norm 1:1000) and nurse-population ratio of at least 1:500 (WHO norm 1:400) by 2

Chapter # 28. Comprehensive Primary Health Care

Objectives  Under Ayushman Bharat, scale-up a new vision for comprehensive primary health care across the country, built on the platform of health an

Chapter # 27. Public Health Management and Action

Objectives  To revamp radically the public and preventive health system in the nation through the following strategic interventions: Mobilize public

Chapter # 26. Skill Development

Obejctives  For harnessing the demographic advantage that it enjoys, India needs to build the capacity and infrastructure for skilling/reskilling/up-

Chapter # 25. Teacher Education and Training

Objectives There cannot be a quality education system without quality teachers. Therefore, a thorough revamp of the entire ecosystem of teacher educat

Chapter # 24. Higher Education

Objectives  Increase the gross enrolment ratio (GER) in higher education from 25 per cent in 2016-17 to 35 per cent by 2022-23. Make higher education

23. School Education

Objectives Universal access and retention: o Hundred per cent enrolment and retention at elementary education and secondary education levels; achieve

Chapter # 22. Sustainable Environment

Objective  The objective is to maintain a clean, green and healthy environment with peoples’ participation to support higher and inclusive economic

Chapter # 21. Water Resources

Objectives By 2022-23, India’s water resources management strategy should facilitate water security to ensure adequate availability of water for l

Chapter # 20. Swash Bharat Mission

Objectives The key objectives of the Swachh Bharat Mission include: 1. Making India Open Defecation Free (ODF) by October 2, 2019. 2. Carrying out ext

Chapter # 19.Smart Cities for Urban Transformation

Objectives  Leverage the ‘Smart Cities’ concept in select urban clusters to: Drive job creation and economic growth. Significantly improve effici

Chapter # 18. Digital Connectivity

Objectives Given the relevance of digital connectivity to economic growth and the need to eliminate the digital divide by 2022-23, India should aim to

Chapter # 17. Logistics

Objectives Achieve multi-modal movement of cargo on par with global logistics standards. Reduce the logistics cost to less than 10 per cent of GDP fro

Chapter # 16.Ports, Shipping and Inland Waterways

Objectives  Double the share of freight transported by coastal shipping and inland waterways from 6 per cent in 2016-171 to 12 per cent by 2025. Incr

Chapter # 15. Civil Aviation

Objectives Enhance the affordability of flying to enable an increase in domestic ticket sales from 103.75 million in 2016-171 to 300 million by 2022.2

Chapter # 14. Railways

Objectives By 2022-23, India should have a rail network that is not only efficient, reliable and safe, but is also cost-effective and accessible, both

Chapter # 13. Surface Transport

Objectives Increasing the coverage and quality of roads and highways is critical to enhancing connectivity and internal and external trade. By 2022-23

Chapter # 12. Energy

Objectives The government’s on-going energy sector policies aim “to provide access to affordable, reliable, sustainable and modern energy”. At t

Chapter # 11. Minerals

Objectives Double the area explored from 10 per cent of obvious geological potential (OGP) area to 20 per cent.1 Accelerate the growth of the mining s

Chapter # 10. Travel, Tourism and Hospitality

Objectives  Increase India’s share in global international tourist arrivals from 1.18 per cent to 3 per cent. Increase the number of foreign touris

Chapter # 9. Housing For All

Objectives Provide every family with a pucca house, with a water connection, toilet facilities, and 24×7 electricity supply and access. Build 2.9

Chapter # 8. Financial Inclusion

Objectives Banking for the unbanked  o Bank accounts: Ensuring universal access to bank accounts, which are a gateway to all financial services.  o

Chapter # 7.Doubling Farmers’ Income (III): Value Chain & Rural Infrastructure

Objectives • Transform the rural economy through the creation of modern rural infrastructure and an integrated value chain system. • Leverage the

Chapter # 6.Doubling Farmers’ Income (II): Policy & Governance

Objectives Create a policy environment that enables income security for farmers, whilst maintaining India’s food security. Encourage the participati

Chapter # 5.Doubling Farmers’ Income (I): Modernizing Agriculture

Objectives • Modernize agricultural technology, increase productivity, efficiency and crop diversification. • Generate income and employment throu

Chapter # 4.Industry

Objectives Double the current growth rate of the manufac-turing sector by 2022. Promote in a planned manner the adoption of the latest technology adva

Chapter # 3. Technology and Innovation

Objectives India should be among the top 50 countries in the Global Innovation Index by 2022-23.1 Five of our scientific research institutions should

Chapter # 2.Employment and Labour Reforms

Objectives Complete codification of central labour laws into four codes by 2019. Increase female labour force participation to at least 30 per cent by

Chapter # 1 Growth (India @ 75)

Objectives Steadily accelerate the gross domestic product(GDP) growth rate to achieve a target of about 8 per cent during 2018-23 This will raise the

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