Take care, all: How it panned out in India

An increase in availability of various interventions at primary level has gone a long way in reduction of diseases. But inequality and mal-distribution of resources persist owing to isolation of primary level health care from comprehensive health plan for the society

Primary health care has two meanings. On the one hand it refers to a level of health care provision, and on the other hand it refers to a philosophy of health system design and functioning. As a level of care it refers to the first point of contact of communities with the formal health system or its representatives.

In India this refers to the network of peripheral health institutions like the primary health centres and the health sub-centres. These are located at the 30,000 and 5,000 population level respectively, meant to cater to the most common needs of the community. Indeed many Plan documents refer to the fact that nearly 60 to 70 per cent of illness episodes in a community can be effectively tackled at that level. This depends on the availability of trained and motivated service providers, infrastructure, drugs and diagnostics and most importantly referral support to higher levels of care, that are timely and accessible.

As a philosophy of health system design and functioning, primary health care is sometimes suffixed with the word ‘Comprehensive’ (and thus CPHC), to differentiate it from what has termed as selective primary health care. Selective PHC is the strategy that reduced the more comprehensive vision of PHC originally envisaged in the Alma-Ata document into a set of “effective” technologies, that were envisaged to improve the health of communities in isolation of the more comprehensive approach envisaged.

CPHC is considered by many as a socio-political philosophy, emphasizing equity in access to health care and the social determinants of health. CPHC refers to universally accessible care on the basis of need; comprehensive set of services across the spectrum of preventive, promotive and rehabilitative; strong component of inter-sectoral coordination between the various other dimensions of development like water, public distribution and education, which are essential for health; active community participation based on the rights of citizens; and appropriate care based on appropriate technology. Most importantly it was premised on the global achievement of a more just economic system referred to in the original Alma-Ata document as the New International Economic Order.

It is clear that primary health care needs to be seen as much more than just a level of care and its philosophical implications on the design of health systems need to be highlighted in any attempt at invoking it as a potential solution to various issues in health care facing us today.

Thus while in general the interpretation of primary health care has been limited to only the most peripheral level of the health system, in reality it was envisaged as a foundational philosophy of the whole health system in a given setting.

As long as the PHC is only interpreted in the sense of levels of care – with the primary level catering to the community and the secondary and tertiary level accepting that health care delivery can be developed as a source of profit that can be bought and sold in the market, the true vision of PHC can never be realized.

While indeed an increase in the availability of various interventions at the primary level on its own will go a long way in the reduction of the particular diseases that they are targeted against, nearly 40 years of such technology and intervention-driven health system development in isolation from the broader macro vision of justice which underlies CPHC has led to the present state of health care, characterized by inequity and mal-distribution of resources.

PHC refers to a vision of health system design that keeps the community at the centre for all levels of care. Thus it entails that not only should the primary level be community centred, but equally and even crucially the secondary and tertiary levels need to be guided by the priorities and the needs of the primary level / community level rather than having an independent and isolated existence.

This is the true vision of PHC. The services cannot be planned only in terms of the curative care, but also needs to be planned in terms of preventive and promotive (and rehabilitative) care as well as in terms of tackling / engaging with the social determinants of health. Such a vision is not possible in isolation but needs to be the basis of development as a whole.

The message of experience of implementing the vision of Alma Ata regarding PHC in various settings over the decades since the clarion call for Health for ALL is clear – the creation of a truly caring and equity-oriented health care system cannot happen in isolation of overall development. To achieve this vision of a health system its evolution needs to be based on the right to health, where individuals and communities are seen as holding individual and collective rights as citizens. This is quite different from their visualization as clients in a market – with entry or access dependent on the ability to pay (even if by insurance).

Many of these insights have been enshrined in the vision of the recent Astana Declaration of the WHO as well as documents such as WHO and UNICEFs Framework for integrated people-centred health services.

The National Rural Health Mission and the subsequent focus on the creation of health and wellness centres have increased attention to the primary level of care. To expand this beyond the limited interpretation of a level alone and to adopt the philosophical underpinnings with all its implications for the design of the health system will be the true challenge in any efforts towards the expansion of primary health care towards Health for ALL.

(The author recently joined Achutha Menon Centre for Health Science Studies as professor after a stint as Senior Scientist, Centre for Technology and Policy, Indian Institute of Technology Madras. His areas of interest are health policy, implementation studies, health systems research and health inequity)