Editing and contributions by Dr. Zeena Johar, President, ICTPH
Primary healthcare in India remains one of the country’s greatest healthcare challenges, despite its tertiary and quaternary treatment meeting the highest of global standards. Around the country, particularly in rural settings, a lack of services at the primary level has forced patients to seek substandard consultation for early stage illnesses, resulting in misdiagnosis and improper treatment that often leads to a need for more advanced and more expensive care. In other situations, patients do not seek consultation at all until an ailment advances to a dangerous stage.
Challenges in Indian primary care stem from both a lack of infrastructure in areas most in need, and a difficulty in staffing these areas with appropriate human resources. The government has responded to this, but inadequately. Guidelines for setting up primary healthcare facilities at the 5,000 population level are included in the public healthcare plan, yet these facilities are not mandated to have a trained physician. Primary care facilities at the 25,000 population level, on the other hand, are required to have trained physicians, but these facilities are often too far to reach by foot and thus out of reach of many rural patients. 
Secondary facilities such as small hospitals set up in Tier 2 and Tier 3 cities offer patients a level of primary care through their outpatient services. However, being the only access to primary care for many localities, outpatient centers in these hospitals are typically so crowded that physicians can only afford to allocate less than a minute of their time to each patient.
This particular challenge extends beyond a lack of healthcare infrastructure. No matter how much money is pumped into hospitals to expand their capacity, the burden of chronic disease in India will continue to ensure that whatever capacity these hospitals have is occupied by reactive care rather than the proactive care needed at the primary level. India has the some of the highest rates of cancer for specific types such as gall bladder, mouth, and lower pharynx.  Additionally, according to the 5th edition of the Diabetes Atlas put out by the International Diabetes Federation (IDF), there are a staggering 63 million people in India between the ages of 20-79 with diabetes. The high prevalence of these diseases forces hospitals and other providers to be in a constant state of reaction, and the proactive care that could reduce the prevalence in the first place becomes neglected.
People often point to technology as a way to compensate for the lack of primary care infrastructure and human resources in the country. Indeed, India has recently seen an influx of relatively inexpensive, high-tech solutions to healthcare challenges, both from abroad and from domestic innovators. Still, the vast majority of these innovations, introduced to the market with a promise to expand the reach of quality healthcare services to those previously without access, remain concentrated in urban areas. From an economic standpoint, it makes sense that these technologies, inexpensive as they may be, would stay concentrated in areas with the highest relative purchasing power. But this does nothing to address the 750 million Indians living outside urban areas and in greatest need of the services provided by these same technologies.
The irony of having such high class tertiary and quaternary services at the cost of such poor standards of primary care is that proper treatment at the primary level is often enough to prevent the need for higher level services. In October 2010, the Planning Commission of India established the High Level Expert Group (HLEG) on Universal Health Care to establish a framework for providing accessible and affordable healthcare to all Indians.  In a November 2011 report, the HLEG pushed for an increase in government attention on primary healthcare in order to curb the country’s overall disease burden. In the report, the group recommended that at least 70% of all health care expenditures should be allocated for primary services, including general information and promotion, curative services, screening, and treatment.