Primary care: the first line of defense

A recent report of the parliamentary Standing Committee on Health has deplored the persistently low levels of funding for health over several years. It observed that funding that was held back could have been utilised to improve primary health services and improve India's lagging health indicators.

The Director General of the World Health Organisation (WHO), Margaret Chan, has called for universal health coverage led by “people-centred primary health care”. The ardent technophile Bill Gates now advocates primary health care as a platform for integrated delivery of major health programmes. Many international organisations, from WHO to the World Bank, are now combining efforts to develop practical indicators to measure the performance of primary health services in providing appropriate and affordable care of assured quality to all.

Is this a nostalgic throwback to 1978, when a WHO-inspired world adopted “Health for All by 2000” as an aspirational goal at Alma-Ata, Kazakhstan, and identified primary health care as the principal pathway? The failure to reach that goal led to scepticism about primary health care and cynicism about the prospects of universal health coverage. Why then the resurgence of advocacy for primary health care?

New global construct

Here are five reasons why we must start revitalising primary care in a new paradigm. The new global construct of primary care differs from the distorted practice of the past. The vision of comprehensive, integrated care was fragmented by vertical health programmes and donor-driven selective primary care. It has been recognised that even well-intended, vertical programmes cannot be successfully force fitted into weak health systems. This has now led to fresh advocacy for comprehensive primary care as the foundation of a strong health system.

The experiences of other low- and middle-income countries show that efficient primary care services can dramatically improve population health indicators. In Brazil, a “family health team”, comprising a doctor, a nurse, a nurse assistant and four to six full-time community health agents, covers up to 1,000 households. Each community health agent covers up to 150 households. This has resulted in improvements in maternal and child health as well as a decline in cardiovascular mortality. Similarly, Thailand has used community health workers in primary care to achieve a leap in health and a sharp decline in malnutrition. Rwanda, with its emphasis on community health workers in primary care, has achieved the steepest ever globally recorded rate of decline in maternal and child mortality in the last two decades.

Trickle-down effect

Primary health care services help to promote health, prevent disease and detect disorders early for effective treatment. By preventing serious complications, they contain overall health expenditure and improve population health outcomes. They also assure continued ambulatory care when patients return from tertiary or secondary care hospitals.

They reduce doctor dependency of the health system. Much of primary care can be provided by trained community health workers, nurses and allied health professionals. Technology-enabled frontline health workers can operate even in remote rural areas where doctors are not available. Many young persons, especially women, can be gainfully employed in socially useful jobs in the primary health workforce.

Well-planned, primary health services comfort people by providing care at home or close to home. They also provide a close connection between the community and public health, with an opportunity for peoples’ participation in the design, delivery and monitoring of health services. They democratise health care.

It is imperative that India invests in a strong primary health care system if it is serious about achieving the health targets set by the Sustainable Development Goals.

K. Srinath Reddy is President, Public Health Foundation of India.

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