Reimagining primary healthcare for a resilient and inclusive future in India

Presentation by Dr. Prashanth N Srinivas, Senior Fellow, IPH Bengaluru at the Wipro Foundation Annual Partners Forum (2025) at Hyderabad on January 23.

1. Dr. Prashanth N S, MBBS, MPH, PhD (Public Health) Senior Fellow & Director, IPH Bengaluru Presentation based on content, inputs and knowledge outputs from Devaki Nambiar, Sapna Desai, Arnab Mukherjee, Nirmala Nair and colleagues of the PHC4UHC research group supported by the WHO Alliance for Health Policy & Systems Research and with members across IPH Bengaluru, Ekjut , The George Institute of Global Health India, Indian Institute of Management, Bangalore Reimagining primary healthcare for a resilient and inclusive future in India

2. Scheme for this Presentation Overview of IPH Bengaluru The case for re-imagining Primary Health Care Primary Health Care as THE core driver for Universal Health Coverage Conceptualizing stronger PHC systems (for UHC): Experience of the PHC4UHC consortium PHC4UHC: Some of the team members

3. Vision To create an equitable, integrated, decentralized, responsive and participatory health system within a just and empowered society Mission Strengthening health systems to ensure healthy communities through a team of committed and value-based professionals

4. www.iphindia.org

5. Global to local project-based engagements & collaborations

6. Case for re-imagining PHC Does systematic investment in PHC still make sense given : Telemedicine, telehealth & an “empowered” consumer in an expanding healthcare market Widespread private sector with options for purchasing care from individual PPs/”primary care packages” from corporate chains Performance issues in ensuring effective delivery of PHCs & HWCs in remote rural areas

7. Case for re-imagining PHC For me these show a lack of imagination & perhaps even a misunderstanding of PHC Digital tech, a new app/smartphone for ASHA, AI/ML enabled “intelligent” architecture, state/national data dashboard will revolutionize PHC With increased economic growth, med-tech & services are now widely available New cadres of CHWs/CHOs/extra ASHA will solve the problem

8. Case for re-imagining PHC Healthcare as free choice or healthcare as a commodity (cf. information asymmetry & market failures in prevention & promotion) vs health(care) as a right  Implications for design of health policy & systems (reforms)  From opportunistic innovations driven by possibilities (of digital tech & big data) to goal-oriented, value-driven reform options (often boring!) that promote equity & inclusion (hence mitigate inequities & exclusions)

9. Case for re-imagining PHC Fragmentations & distortions Components : Prev & prom, cur & rehab Clinical Specialties Services & programs : both diseases (ICTC counsellor for eg. Not available for self-harm), age group/demography based programs (RBSK driven school health for eg. ) Healthcare professions : sub-specialization, professional consolidation, & marginalization (midwifery for eg ) Systems of healthcare Governance fragmentation : see next slide with situation of same family having diff providers & provider systems AN eg. Of an Adivasi migrant for instance – despite digital health stack & such and despite theoretical possibility of continuity of care across the country & inter-operability  in practice nothing different from a decade ago Extreme individuation that sometimes comes at an opportunity cost – VC/investment/AI driven push for personalized/precision med

10. Source: WHO APO 2022

11. PHC: Imaginations & evolution Early origins in community & social movements  universality of access to health(care) as an underlying principle irrespective of….. Decentralised PHC as an organizing principle of the system itself Higher care as contingent upon strong PHC Tensions with sPHC , disease control  return of CPHC (leadership of NHSRC & civil society movements in India)

12. Universal Health Coverage WHO & global health actors’ move towards UHC as the common meeting point of multiple global-national health/healthcare aspirations UHC’s focus on measurement (double-edged) Reductionist framing of UHC coverage vs care Coverage of what (insurance? Schemes?) Locating/ visibilising PHC within UHC

13. Pathways to UHC in India Wide variations in UHC performance at the district level: within states and across state boundaries Reflects importance of health system design, functioning and other determinants Study team recently conducted a 6 district study on pathways to UHC as part of Lancet Commission on Reimagining India’s Health Systems Adapted from WHO-World Bank UHC index to India’s districts (Mukherji A et al 2024) Slide source: PHC4UHC/WHO Alliance for HPSR

14. Exploring pathways from PHC to UHC: A participatory learning lab

15. Aim To understand the how PHC interventions (integrated services, empowered communities, and multisectoral action) can contribute to advancing UHC (enhanced population coverage, service coverage, and financial risk protection) in India. Objectives To understand: Indian government policies and programmes related to PHC and PHC service coverage Contextual and implementation factors that influence how PHC can contribute to UHC Associated facilitators and barriers Gaps, priorities and solutions to advance the path from PHC towards UHC Slide source: PHC4UHC/WHO Alliance for HPSR

16. Service Delivery

17. National Flagship Ayushman Bharat – Health & Wellness Centres (AB-HWC) Launched in 2018 Shift from selective to comprehensive primary healthcare Reforms span service delivery, human resources, financing, access to medicines and diagnostics, community participation, accountability and governance SHCs & PHCs upgraded to HWC-SHC, HWC-PHC Addition of Community Health Officers to lead primary healthcare team Slide source: PHC4UHC/WHO Alliance for HPSR

18. Expanding Services and Access (State-level) Aardram Mission, Kerala Key focus on transforming PHCs to Family Health Clinics Inputs include infrastructural improvements, human resource training, record management through the e-Health system, improved laboratory facilities and amore preventive rather than curative outlook towards healthcare service provision Aam Aadmi Mohalla Clinic, Delhi Provide quality, easily accessible, primary health care services to underserved populations in urban settings (eg: unauthorized colonies, slums, densely populated areas) Basic medical care based on standard treatment protocols (eg: curative care for common illnesses, first aid for injuries and burns, and referral services) Drugs provided free of cost; diagnostic tests carried out by empanelled labs Slide source: PHC4UHC/WHO Alliance for HPSR

19. Free Evening Specialist Clinics at UPHCs, Telangana Paediatrician consultation Diagnostic tests and reports Drugs and immunization Hamar Aspataal, Chhattisgarh Addressing OPD centric primary health care services in urban areas Infrastructure upgradation of UPHCs, expanded scope of services and modified OPD hours (8-2 pm, 2-8 pm) Boat Clinics, Assam Launched to improve health of marginalized riverine population in state Each Boat Clinic unit comprises of 1-2 Medical Officers, 2-3 ANMs, 1 Pharmacist, 1 Laboratory Technician, 3 Community Workers and four Boat Crew Main thrust of program is to provide RMNCH services, basic laboratory services, health education, free medicines Slide source: PHC4UHC/WHO Alliance for HPSR

20. Aarogya Samanvay, Gujarat Aimed at providing integrated Allopathic, Ayurvedic and Yoga services, spanning RMNCH+A, communicable and non-communicable diseases, oral care, geriatric and palliative care at SHC-HWCs CHOs are trained for 21 days to provide Ayurvedic services, yoga, and home-based services at SHC-HWCs Vision centres in Urban PHCs, Bihar Eye OPD services provided at UPHCs include eye screening at outreach camps through existing human resources ASHAs and MAS members trained to create referral linkages from community to facilities Slide source: PHC4UHC/WHO Alliance for HPSR

21. Janch Mitan, Chhattisgarh Hub & spoke model for diagnostics at PHCs without lab technicians Volunteers - Janch Mitan (runners) - transport samples from facilities to testing centres Geriatric day care centres, Himachal Pradesh Provision of comprehensive services, particularly in areas with high geriatric load, in partnership with HelpAge India Weekly health check ups, provision of free medicines, physiotherapy sessions, health awareness, digital literacy classes, legal aid and counselling etc. Slide source: PHC4UHC/WHO Alliance for HPSR

22. RMNCH Antara Tele-consultations, Rajasthan Unmet need for contraception addressed by allowing trained ANMs to administer first dose of injectable contraceptives to new clients after telephonic screening by trained medical officer Nurse Practitioner Midwifery training, Telangana To address shortage of trained specialists, high c-section rates, respectful maternity care, 18 month NPM training initiated Slide source: PHC4UHC/WHO Alliance for HPSR

23. Disease-specific Malaria Mukt Bastar Abhiyan, Chhattisgarh Active mass screening including door-to-door survey Wall stickers/stencils pasted outside surveyed houses; toenail marking to identify those who tested positive Intersectoral efforts with depts of women & child dept, education, forests, tribes, fisheries, panchayati & rural development, public health & engineering Nikshay Mitra, Jharkhand Nodal person identified and assigned by the Private Health Care Facility for TB related activities and are incentivized for his/her activities Coordinates between levels and across facilities, provides counselling, collects information from patients and specimens for testing, records treatment adherence and outcomes Slide source: PHC4UHC/WHO Alliance for HPSR

24. Active Case Finding for Leprosy in evening hours, Dadra & Nagar Haveli To address high prevalence of leprosy, active case finding survey timing modified to include later evening hours to cover those working outside home/unavailable during day time Cough & Cold Centres, Dadra & Nagar Haveli, Daman & Diu Centres within OPD areas to identify and separate patients with respiratory symptoms to avail immediate and appropriate services Sputum collection spot separate from other OPD attendees Tickler Bag to monitor and supervised diagnosed NCD patients, Assam Copy of NCD cards retained in tickler bag placed at HWCs to track status of follow-up with month (dropped out/left out/treatment complete) Inclusion of HPV vaccine in routine immunization, Sikkim State-wide immunization for HPV was initiated free of cost School HPV vaccination drive, media sensitization, vaccine cards etc. Slide source: PHC4UHC/WHO Alliance for HPSR

25. Empowered Communities

26. National Village Health, Sanitation and Nutrition Committee Envisioned as key mechanism for decentralized health planning Formed to take collective action health issues and social determinants at village level Mahila Arogya Samitis To promote local collective action for health in urban areas Facilitated by the ASHA, who acts as the member secretary Jan Arogya Samiti Formed at SHC-HWC level Community participation in management, governance and ensuring accountability Serve as umbrella for VHSNCs, supporting & providing mentorship to VHSNCs Slide source: PHC4UHC/WHO Alliance for HPSR

27. State-specific Participatory Learning and Action cycle with ASHAs, Jharkhand comprises of a series of meetings where community groups discuss, learn and engage in participatory decision-making ASHAs conduct meetings with community groups comprising of all women and men, adolescent girls and boys, pregnant and lactating women, other community health workers, panchayat and VHSNC representatives Village Health Councils, Meghalaya envisioned as nodal community institution to mobilise action on health and nutrition and serve as a link between the health system and communities, replacing VHSNCs in state comprise of elected, rather than appointed, officials, including leadership from Meghalaya’s traditional institutions and village organization presidents from women’s self-help groups, ASHAs, Anganwadi workers and teachers Slide source: PHC4UHC/WHO Alliance for HPSR

28. Multisectoral Action

29. Health & Rural Development (National) Food Nutrition Health & WASH intervention DAY-NRLM issued Master Circular to promote FNHW (2017) to guide states on “layering” these onto core SHG activities Aimed at increasing knowledge on these issues as well as access to entitlements and overall, behavior change selected SHG members trained and placed as CRPs for undertaking FNHW interventions and other social development issues and establishing linkages with the services of related departments Slide source: PHC4UHC/WHO Alliance for HPSR

30. Health & Rural Development (Tamil Nadu) Women Health Volunteers (WHVs), Tamil Nadu Recruited through SRLM and funded by Dept of Health as community health workers Key focus on population based screening & home visits to improve NCD detection, referral and follow-up Makkalai Thedi Mauvthuvam (MTM) launched in 2021: WHVs deliver drugs to NCD patients Convergence enabled through MoU between NHM-TN and TN-CDW Mental health programme Implemented by TNSRLM in convergence with Depts of health and PRI, in partnership with ‘SCARF India Foundation’ and ‘TN Volunteers Resource Centre’ Mental health screening done through camps to identify diasblities and suspected cases are referred further Physiotherapy, vocational training, and loans are provided to the needy for successful rehabilitation and making a livelihood Slide source: PHC4UHC/WHO Alliance for HPSR

31. Health & Rural Development (Odisha) Institutionalized involvement of SHGs through government guidelines Active in Malaria control through IEC, activities, long-lasting insecticidal nets (LLIN) distribution, community mobilization, monitoring etc. Involved in housekeeping and cleanliness activities, observation of “health days” at AB-HWC/SHC/PHC levels, Transport samples from PHC to nearest diagnostic hub (CHC/ SDH/ DH), alternative vaccine delivery, sputum transport, supply of sanitary pads, e tc. Slide source: PHC4UHC/WHO Alliance for HPSR

32. Health & Rural Development (Bihar, Odisha, Chhattisgarh) Swabhimaan Five-year initiative (2016-21) integrated within DAY-NRLM, carried out in partnership with UNICEF Aimed to mobilise women via village-level women’s collectives to develop and implement integrated nutrition microplans and strengthen local government services in order to improve the nutrition outcomes of women and adolescent girls Slide source: PHC4UHC/WHO Alliance for HPSR

33. Health, Social Welfare, and Rural Development (Meghalaya) S ector Meetings Representatives from three depts attend regular Sector Meetings at PHC/CHC levels to improve service delivery and community action for health Intended to facilitate teamwork & accountability between the different departments and with communities, particularly women’s groups Community Gender & Health Activists MSRLS cadre drawn from SHGs meant to support ASHAs with home visits and strengthen social and behaviour change through awareness on food, nutrition, health and sanitation amongst communities Slide source: PHC4UHC/WHO Alliance for HPSR

34. Karnataka Arogya Bandhu: PPP agreement with pvt medical colleges and other agencies in management of PHCs (and associated SHCs) Involves infrastructure, facilities, instruments and equipment, drugs and supplies, and staff on deputation Meghalaya Chief Minister’s Safe Motherhood Scheme provides mobility support for ANMs to support community awareness in villages Flexible funding at PHCs/CHCs to arrange dedicated vehicles to support transportation of pregnant women for maternity care Compensation for time spent by attendants or Traditional Birth attendants to encourage family members to accompany the mother and stay with them Puducherry Pilot project set up to establish a diabetes registry in the primary health care setting of Puducherry Purpose: to make registry sustainable and replicable, implementation within existing system of primary health care crucial Beyond PHC framework Slide source: PHC4UHC/WHO Alliance for HPSR

35. Case of HWC

36. Participatory Learning and Action Groups in National Health Mission 

37. Participatory Learning and Action group meetings for PVTG Population- Gumla and Sahibganj

38. Tribal Health Navigator (Karnataka)

39. THNs from Chamarajanagar district

40. More communities served by PHC systems More communities advocate for care needs Varying sub-community needs outside health sector addressed PHC care widened to correspond with actual needs Processes exist for -(communities to articulate needs; reflect on availability, accessibility, acceptability quality of services Linkages to needed services outside the health sector available, accessible, acceptable and of quality Appropriate linkages between services and cost reduction mechanisms Communities involved in pricing; costing approaches/ finance to cater to population subgroups Enhanced interoperability and linkages with government welfare and social protection schemes Mechanisms More populations covered by flagship UHC/health reform interventions with reduced inequalities over time Wider range of services incrementally covered across continuum of care and life course Substantially reduced OOPE and income/employment losses attributable to health across all populations UHC Outcomes Integrated services Community engagement Multisectoral action HWC 1,2,3, 5, 7 PLA 1,2,3, 4,5 THN 1,3,4,9 PHC Case (1) (2) (3) (4) (5) (6) (7) (8) (9) So what could a (reimagined) PHC look like for inclusiveness & resilience

41. Exploring the pathways between PHC and UHC in India

42. THANK YOU