A Cure To India's Ailing Primary Healthcare?Will Sloan
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.
Models of a primary care centred system are out there for India to learn from. Even in certain developing countries like Mexico and Thailand, primary healthcare serves as the foundation and gate-keeper for all higher levels of treatment. In these systems, registered primary care centres act as the patient’s first point of contact with the healthcare system and refer patients to higher levels of care on a per need basis.
Getting qualified personnel to areas most in need is another challenge of primary healthcare services. For this, however, promising solutions exist within the Indian system. In many instances of primary treatment, a medical degree might not be required to perform the necessary service. India is home to hundreds of thousands of trained practitioners of alternative medicine such as Ayurveda and Unani. Many of these practitioners are legally permitted to provide allopathic treatment to patients; however, a gap exists between these practitioners and MBBS physicians in terms of their grasp of modern pharmacology.  Courses designed to bridge this gap between alternative practices and the needs within allopathic primary care, such as the one offered by ICTPH, offer great promise to solving the personnel issue in Indian primary healthcare.
Though repercussions are more acute in certain margins of society, the problems in the primary healthcare space affect everyone, regardless of caste, geography, or socioeconomic status. Still, there seems to be confusion regarding where to look for a solution to these problems. Some point to an improved government effort with increased attention and more focused spending as the solution. Others point to the emergence of new technologies in the healthcare space as a panacea for all existing challenges. The reality, however, is that no matter how much public funding and technological innovation we see, neither one has the ability to solve the problems on its own.
The key question facing the primary healthcare space right now is not who is going to solve the problems, but, rather, how do we develop a holistic ecosystem that incorporates the value additions of all stakeholders simultaneously. A thriving primary healthcare space depends not only on government support or technology, but also innovations in business, private funding, trained personnel and systems to incentivize them to work in areas of need, support from insurance providers, and conducive interaction between the primary level and higher levels of medical care.
Most of these factors already exist, albeit in isolation, and others can be achieved without much difficulty. Thus, while the current primary healthcare landscape in India might itself seem ill, a cure is perhaps not out of reach. The solution, in fact, might not require a new remedy, but rather a different way of looking at the remedies that already exist, and new channels for collaboration and collective impact among them. As we work to design this solution, it is essential that we expand our focus beyond one particular stakeholder or institution and view all of these areas as points in a network with the single goal of quality primary healthcare for all.
About The Editor:
Zeena Johar returned to India after obtaining her PhD in Molecular Diagnostics at ETH, Zurich, Switzerland in 2007. As the Founding Member, Zeena led the incorporation of SughaVazhvu Healthcare and IKP Centre for Technologies in Public Health (ICTPH) which are currently disrupting rural Indian health care delivery. Zeena serves as the President at ICTPH and MD & CEO at SughaVazhvu Healthcare. Having launched its first Rural Micro Health Centre (RMHC) in November, 2009, in Thanjavur (Rural India), SughaVazhvu Healthcare today has a network of seven RMHCs reaching 70,000 rural residents. Under Zeena’s leadership, the design innovation at SughaVazhvu Healthcare has made services such as ophthalmology, basic dental hygiene, cervical screening, along with acute and chronic disease management accessible to underserved rural residents and has paved a way for creation of a sustainable nationwide primary healthcare system.