1. Primary Heath Care
Arjun Mehta
Kanika Vyas
Neha Saini
Rohan Wahane
Tarun Arora
1
IIM Lucknow

2. Executive Summary
2
Facts related
to health care
Problems
faced by India
Approach
taken
Key highlights
and solutions
Vision 2025
Flow of the presentation
India has some of the best tertiary care in the world and is gradually acquiring a name for itself even in the field of 'medical
tourism'. Secondary care is still a significant challenge, but even in several smaller towns and district headquarters, there is a
growing supply of maternity homes and multi-speciality secondary care facilities. In all of these systems, primary care forms
the anchor around which the entire system is built and there is a high level of integration between various levels of care with
strong gate-keeping and patient management functions being performed by the primary healthcare providers. The actual
situation in this regard on the ground in India is very grim. In most parts of the country, formal primary care is virtually non-
existent. Within the urban context, there is a some amount of formal primary care available in the form of general
practitioners, ophthalmologists, dentists, etc. We have identified operational issues in the system and provided a solution that
how partnerships can improve the face of primary system in India.

3. Where does India stand ?
3
21% Global disease burden and largest
communicable disease burden with India
3rd Highest among countries with
high rate of HIV-infected persons
33% Lack access to proper sanitation
3.3 per 10,000
Doctors in rural areas as compared
to 13.3 per 10,000 in urban areas
• Grossly underfunded, under staffed, and poorly equipped
• Allopathic physicians highly concentrated in urban areas
• Similar trends in concentration of nurses and midwives
Public Health Infrastructure
• Both urban and rural Indian households tend to use private medical sector
more frequently than public sector
• Due to poor level of quality care in public sector
• Long wait lines, inconvenient hours of operation and distance of public sector
facility
Private Health Care
• Public spending on health care in India as low as 0.9% of GDP in contrast to
total health expenditure of 5% of GDP
• Decreasing public health expenditure has adversely affected the health
outcomes
Health Care Costs
• Only 25% of rural population has availability to piped water as compared to
75% in urban areas
• Only 20% of total hospital beds in rural areas which have 68% of India’s
population
• Infant mortality rate in poorest 20% 2.5 times higher than the richest 20%
Urban Rural Disparities

4. Communicable diseases have a major impact on
the decrease in lives of people. Majorly due to
unawareness, carelessness and not taking
enough precautions.
The nurses ratio to population which stands at
current 0.1% is very less and needs
improvements.
Major reason for maximum infant death is
non availability of medicines at the right
time.
We need to work on improving current
levels of sanitation and water cleanliness in
order to establish intrusive development
Private Infrastructure has improved but we are
delivering half of what is a global average and
not even close to WHO guidelines
WHO survey ranks India 171 out of 175, in
terms of total GDP spent on healthcare. Nepal,
Bangladesh are better than India. Also the
utilization percentage of the budget is not 100%
Key Issues and Ground Realities

5. Inadequate human resources to
staff primary care, evidenced by
limited ability to recruit and
retain high quality staff,
particularly in disadvantaged
areas
Failure to deliver universally the
key primary care services
necessary to reach MDG targets
(vaccination, nutrition and
hygiene support, safe maternity
services, effective first contact
acute care for serious disease)
Failure to deliver effectively the
primary care services which
reduce health system costs
(prevention and care of chronic
diseases, effective diagnosis and
prioritization for hospital referral)
Lack of public and clinical
governance of performance
Poor leadership, public regard,
and professional status
Problems Identified
Overall generic problems
5
Underlying operational problems
Funding Models1
• Funding models that are unresponsive to the value of high quality acute,
preventive, and chronic care outside hospital
Distribution and Financing Schemes2
• Distribution and financing mechanisms for medicines that do not take advantage of
the availability of effective generic medicines
Information Systems3
• Lack of effective information systems, including failure to exploit the opportunities
for patient involvement in self care inherent in modern information technology
Human Resources4
• Multiskilling i.e. training individuals to perform tasks within their capacity but
beyond their traditional professional roles which will allow the available workforce
in the team to be deployed most efficiently

6. Problem Summary
• Primary care is an extremely unattractive
career for allopathic doctors
• Virtually no community based postgraduate
training and poor career prospects
• 10% of posts for doctors at the PHCs and
63% of the specialist posts at the CHCs, and
25% of the nursing posts at PHCs and CHCs
combined remained unfilled
• 27% of pharmacist and 50% of laboratory
technician posts also vacant
Human Resources
Platforms to build on
•Training and professional support for
nurses and other staff in primary care
teams
•Develop enhanced specialist roles by
partnership between professional
bodies, Universities, and private
educational providers
•Specific areas of reported need which
could be met include emergency
medicine, child health, orthopedics
•Tie up with countries of special repute
in Health Care in training and
implementation development
•Disciplines that need support in
delivering enhanced skills training
include physiotherapists, dieticians,
paramedics and therapists
Strategic Points
• Introduce incentive schemes—monetary
and non-monetary—and compulsory service
bonds to enhance recruitment of good
doctors to rural areas
• Establish partnership with international
colleges of repute for nurse training
• Establish new nurse institutes on the lines of
ITI across India. Award special economic and
infrastructure status to these institutes
• Preference for admission to education and
training courses for doctors and to local
students from rural and underserved areas
• Preference to clinical workers of local areas
for postgraduate training, financial
incentives, communication facilities, and
opportunities for education of their children
• Reintroduce compulsory service in
underserved areas by all medical graduates

7. Problem Summary
• Major difference in MDG health indicators
between urban and rural areas and between
states
• India is also off- track to meeting its declared
national and MDG targets for child mortality
• Projected infant mortality rate between
states varies 12-fold, from 5/1000 in Goa to
58/1000 in Madhya Pradesh and Meghalaya
• Failure to vaccinate and treat the common
childhood infections effectively
• Poor supply and distribution of vaccines,
including cold chain failures, are reported to
be common despite India being a major
vaccine producer
Universal Services
Platforms to build on
• Technical advisory teams (TASTs) for
provision of expert support from
multi nation and Indian expertise
• Development of local capacity and
sustainability
• Use of modern technology for early
recognition of the acutely ill child in
community settings both in
measuring vital signs and by parent
involvement
• Can be at a system (help line
numbers) or an individual level
(using mobile) as a means of
communication with the parent or
for distance monitoring system
• Strong potential for R&D partnership
with the IT and health technology
sector in India to develop innovative
affordable technologies with very
wide scale application
Strategic Points
• Build on innovative and effective
community development activities
• Employ social health activists and auxiliary
midwives, establishing local sanitation
committees, and organize emergency
transport systems
• Innovative approaches to obstetric care that
have reduced maternal mortality by building
effective local teams integrating primary
and hospital care
• Ensure that women have access to high
quality antenatal care as well as increasing
the number of births taking place in a safe
environment

8. Problem Summary
• Chronic diseases (such as heart disease, diabetes)are
the leading cause of death and disability in India.
• Care currently provided by the private sector and
is expensive.
• A substantial proportion of the population receive
no treatment (47% of diabetics and 91% of those
with angina)
• Restricted availability of preventive care, particularly
in poor and rural populations, increasing the burden
of disease.
• Detection of chronic at later stage due to lack of
systematic screening
• The lack of a strong primary care function also
means that diagnostic triage for both acute and
chronic disease is usually conducted by hospital
based doctors.
•high levels of investigation
• use of more expensive non-generic medicines
•potential for inappropriate management by
someone working outside their area of specialist
expertise.
• Unavailability of cost effective generic in primary
care; nor are they routinely used when they are
available.
Strengthening capacity to deliver services which reduce system cost
Strategic Points
• India has a major advantage in dealing with its
epidemic of chronic disease because its generic
pharmaceutical companies produce high quality
medicines at cheapest prices in the world.
• Effectiveness of Health workers at managing chronic
mental health problems (both anxiety & depression)
• Effectiveness of the diagnostic triage function with
access to standard diagnostic facilities like blood
tests, ultrasound, and imaging.
• Effectiveness of technology assisted self care (self-
monitoring of blood pressure, blood glucose) in
reducing morbidity and mortality.
•Self-management of chronic illness also reduces
healthcare workload and costs essential diagnostic
and monitoring technologies
•Affordable cost
• Allow real time monitoring or screening for a range
of other chronic diseases like diabetes
Platforms to build on
•Primary care doctors making referral
decisions on the basis of accurate
diagnoses and managing most patients
in the community according to evidence
based guidelines using generic drugs
•Creating PPP initiatives and developing
innovative care pathways for chronic
care and achieving a level of staff
motivation
•Facilitating the use of computerized
medical records and patient
management systems for chronic
disease prevention and management
•Developing a cadre of primary care
based advanced nurses specializing in
chronic diseases as well as nurses and
healthcare workers working at less
specialized levels
•Benefit : Provides a career framework
for health workers to become
advanced nurse specialists
•Starting at the level of the ASHA
worker and ending with an advanced
nurse practitioner.

9. Problem Summary
• Major variations between states in the
efficacy of governance.
• Limited knowledge in local governance
• Outcome of care not being monitored
effectively.
• Poor quality services, wastage, corruption.
weak management characterise primary
healthcare institutions.
• Problem of ‘ghost workers’ with up to a
50% absentee rate
• Huge unexplained variation in both within
and between states.
• public and private sectors
• differently qualified practitioners in drug
prescribing and frequency of surgical
interventions
• Inadequacy of training and attitudes to
deliver care of a consistently good standard.
Strengthening public and clinical governance
Platforms to build on
•Building effective internal investigation
and inquiry to track poor governance in
the health services and documenting
them.
•Karnataka, have already instituted
strong governance programmes based
on community involvement and
decentralised planning leading to
improvements in health outcomes.
•Andhra Pradesh has established health
financing schemes (to improve the
access of below poverty line families to
secondary and tertiary care) which are
built on IT platforms aimed at ensuring
clinical, financial, and administrative
governance. Such systems could
potentially be extended into primary
care.
• Taking a cue from the corporates and
starting an appraisal system on
performance basis for each primary
care clinician based on quality outcome
standards and patient feedback
Strategic Points
•Remuneration for primary care to be based on
assessment of performance against evidence
based on nationally agreed quality standards.
Adherence to these standards is assessed by
central electronic interrogation of computerised
patient records.
•All clinical activity undertaken in primary care
facilities, including prescribing and recording of
medical records, should be electronic & linked
with financial management system.
•At district level all financial and clinical
performance of all primary care centres to be
overseen by NRHM
•Creating a network of primary care providers to
develop a demand led situation—giving
patients choice to register with the right
primary care provider
•Conducting a nationally annual survey to
evaluate consumer satisfaction with primary
recording patient views about service quality
and ease of access.
•Creating IT support for clinical decisions by
doctors and self-care by patients to improve
care quality and clinical governance.

10. Problem Summary
• Primary care is not yet recognized by the
Medical Council of India (MCI) as a
specialty
• Primary care practitioners therefore have
no formal postgraduate training, no
specialist accreditation, and no system for
career progression
• They have lower pay and worse working
conditions than their hospital colleagues
• Lack of appropriate training or
qualification does not at present appear
to be a barrier to employment as a
primary care doctor
• The current primary care structure
requires recruitment of doctors to posts in
rural areas where basic housing and
education along with facilities for
personal healthcare may be poor
• Failure to recruit quality practitioners to
primary care over many years means that
there is no pool of well trained and
motivated primary care practitioners to
act as leaders and university faculty and
train the next generation
Primary Care Leadership
Platforms to build on
• The professional regulatory councils
in India can do much to support the
development of primary care.
• Great potential to share knowledge
and expertise with international
counterparts on how to promote the
training and recognition of primary
care practitioners.
• Links between nursing faculties are
limited. There is an opportunity to
remedy this and provide greater
support for the efforts of Indian
medical and nursing colleges to
establish academic departments of
primary care
• Partnership in establishing
national/state conferences on
primary care as a regular tradition
• Provide leadership training for
primary care clinicians in India by
partnering with international
Primary Health Care organizations
Strategic Points
• The high quality diagnostic and curative
primary care offered by doctors working in
major hospital outpatients and polyclinics
is limited in scope and function
• But possible starting point with greater
capacity to develop effective clinical
services working to international quality
standards
• Recently established family practice models
may evolve into a cohort of high quality
community based primary care centers
that could support training
• Harness public support to strengthen
health literacy among the public and refine
people’s expectations so that they begin to
understand the risks of overmedication and
over investigation

11. Primary Healthcare : India vs.
Brazil
Key takers from Brazil
(2010 vs. 1965)
• Health Insurance reach –
100%
• Doctor density: 1.7 per
1000– 425% rise
• Public expenditure: 4.2% -
200% rise
• Infant Mortality – 15 per
1000 births (Global : 38)
TransformingHealth System : Political leadership -> Major
Role
Creating universal access: Primary Focus, Secondary
focuson efficiency or quality
High allocation from Primary Healthcarein Union
Budget
Governmentshould choosebetween payer or provider
role
Decentralized Federal System supported by common policy
framework
Key learnings from Brazil
Envisioning India 2025
Improved Financial Access
•Extensive Insurance cover which should move up from current 25% to 75%
•Those who cannot pay for healthcare would receive it for free under public provision
•Authentication and record setup done through the UID card
HealthCare resource Gaps
•Healthcare must be include under infrastructure industry
•Overall Bed density should reach 2.5 per 1000 (current: 1.3/1000)
•1.5 beds per rural areas and 3.8 beds in urban areas(current 0.3/1000 & 3.4/1000)
Workforce Improvement
•Upto 90% registered practioners must be working effectively
•AYUSH & Rural Medical Practioners need to be incorporated into mainstream healthcare at national level
•Doctor density should increase to 0.9/1000 with doctor to nurse ration maintained at 1:2
More Budgetary Allocation
• At least 5.5% of Annual Budgetary expenditure must be allocated to
Primary Healthcare with focus on sanitation and clean drinking water
Integration of health facilities
• Public-private partnership and tracking of patient treatments
Generic Medicines
• Decrease on export of generic medicines and more effective utilization in
the current Indian Setup
• Increase in awareness among rural and urban areas regarding generics
• Improvement in Generics Distribution across the nation
Vision 2025

12. • Glossary
• ASHA :(Accredited Social Health Activist)
• WHO – World Health Organisation
• References
• Central Bureau of Health Intelligence in health sector, 2005&2010
• World Bank database
• WDI
• WHO
• Global Health Expenditure Database
• 12th 5year plan
• http://indiabudget.nic.in
• Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing healthcare for all: challenges
and opportunities. Lancet 2011;377:668-79.
• Patel V, Kumar AK, Paul VK, Rao KD, Reddy KS. Universal health care in India: the time is right. Lancet
2011;377:448-9
• Rao M, Rao KD, Kumar AK, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98.
• Sudarshan H, Prashanth NS. Good governance in health care: the Karnataka experience. Lancet 2011;377:790-2.
• Vision 2015. Medical Council of India. March 2011. www.mciindia.org/tools/announcement/MCI_booklet.pdf.
• Sundararaman T, Gupta G. Indian approaches to retaining skilled health workers in rural areas. Bull World Health
Organ 2011;89:73-7
Appendix and References
Thank You