Strengthening primary care in rural India: Lessons from Indian and global evidence and experience.

India has made significant advances in health of its populations over more than a decade, reducing the gap between rural and urban areas and between the rich and the poor. Huge disparities, however, still remain, and access to healthcare in rural areas remains a huge challenge. A one-day National Consultation, nested within the World Rural Health Conference, was held to share learnings from experiences and evidence of rural primary healthcare within India and from across the world, to identify elements that may guide improvements in healthcare in rural India. From discussions, this article summarizes the evidence on what works for rural primary care, and then provides recommendations for strengthening healthcare in rural India.

Background and Context

India has made significant advances in health of its populations over more than a decade, reducing the gap between rural and urban areas and between the rich and the poor. Huge disparities, however, still remain, and access to healthcare in rural areas still remains a huge challenge. There is a growing recognition that India needs to build a strong comprehensive primary healthcare system to accomplish any further advancements in health status of the populations and to reduce these disparities.

National Health Policy 2016 and budgetary announcements of the year 2018 named as Ayushman Bharat have two components of strengthening healthcare in India: improving access and quality of primary healthcare through strengthening 1,50,000 subcenters and primary health centers (PHCs) [transforming them to health and wellness centers (H and WC)], and improving access to secondary and tertiary care through a near-universal health insurance scheme.

India's economy is growing well, rural infrastructure is improving, and it has access to technology, all of which have the potential to transform health status of its populations. Some state governments have designed and implemented innovative solutions to address the problems of access and affordability of healthcare. Many not-for-profit organizations that work in difficult-to-reach rural areas have innovated to improve access, responsiveness, and quality of primary healthcare. There are also substantial, long-term experiences of several countries that have addressed the problem of delivering universal, high-quality primary healthcare to the most underserved populations.

These experiences can inform and guide India's policy directions into action. A one-day National Consultation was held to share learnings from experiences and evidence of rural primary healthcare within India and from across the world, with the purpose of identifying those elements that could guide India's efforts at improving healthcare in rural and underserved areas. The consultation was nested within World Rural Health Conference 2018, held in New Delhi from 26th to 29th April 2018.

The consultation brought together a range of healthcare practitioners, policy makers, and academicians from India and other countries, developed and developing, They presented the experiences from four states of India (Chhattisgarh, Tamil Nadu, Karnataka, and Rajasthan) and four countries across the world (Australia, Brazil, South Africa, and Nepal), besides drawing on global evidence. This article provides the summary of discussions and key recommendations emerging from the consultation, especially those that have a relevance for rural India. The full report is accessible at: https://bhs.org.in/wp-content/uploads/2019/02/Rural-Primary-Care-Report.pdf.

Evidence on What Works for Rural Primary Care

Family-centered healthcare

There is overwhelming evidence that family-centered care that takes a population health approach and that delivers comprehensive and continuing care helps improve healthcare of rural populations.

Such a care integrates preventive and promotive care and is delivered by health providers (doctors, nurses and other health professionals) who are trained to manage a range of conditions: from safe childbirths to cardiovascular conditions and respiratory conditions. They are further trained to work in teams, understand community needs, and engage them actively.

Higher investments in healthcare

India spends a small proportion of its budget on healthcare. Increased budgetary allocations to National Rural Health Mission led to significantly improved health outcomes: most of this improvement occurred in rural areas, reducing health inequalities. However, overall budgetary allocations to healthcare remain low, around 1% of gross domestic product (GDP), restricting optimal improvements.

Within India, there is a clear evidence that states that spend higher proportions of their budgets on healthcare have better health outcomes than those who spend smaller lesser. There are concerns in South Africa and Brazil that reduced public expenditures in primary healthcare will inhibit provision of healthcare to the most marginalized populations.

State-funded health insurance and implications for primary healthcare

There are concerns that India's investments in the Pradhan Mantri – Jan Arogya Yojna (PMJAY) will promote secondary and tertiary healthcare, at the expense of primary healthcare. The consultation brought about evidence and experience that will be helpful for India to turn this around: helping the PMJAY strengthen rather than weaken primary healthcare.

First, PMJAY could include primary healthcare services. There are several examples: in high-income countries such as Australia and in low-middle-income countries such as Thailand, where state-funded health insurance covers primary healthcare in rural areas. Second, PHCs should retain the gatekeeping functions: patients should first present at PHCs, and only when referred by PHCs, should they be entitled for insurance cover under PMJAY for secondary or tertiary care. Such an arrangement would help in increasing utilization of PHCs and maintain the primacy of primary healthcare. It would also help in ensuring efficiency by reducing unnecessary referrals.

Building and empowering primary healthcare teams

Most presentations highlighted the need for comprehensiveness of healthcare: ability to prevent and treat maternal and child health conditions, and communicable and noncommunicable diseases and injuries.

Because of shortage of physicians to work in rural areas, various government and non-governmental organizations have engaged nonphysician providers to deliver healthcare in rural areas. For example, in Chhattisgarh, a new cadre of rural medical assistants helped in significantly improving the utilization of PHCs in some of the remotest areas of Chhattisgarh. A review of global evidence, shared by WHO India Country Office, concluded that nonphysician providers, when well-skilled, supported, and supervised, can deliver good quality healthcare for a range of conditions.

It was, however, contested that India has a shortage of physicians: their nonavailability reflects inadequate living and working conditions, low wages, and poor training opportunities (see next section). Although the role of nonphysician or mid-level providers was considered important to improve access, many experiences shared in the consultation, such as that from South Africa, Rajasthan, and Chhattisgarh, highlighted a team approach. The team includes a physician (a family physician or a generalist) and nonphysicians: nurses, other healthcare providers, and community health workers. Such a team appears to be critical to provide comprehensive primary healthcare through improved access, quality of care, culturally sensitive care, and equity.

Training of rural healthcare professionals

Global evidence suggests that such a care is effectively provided by workforce (especially doctors and nurses) who are trained to practice comprehensive healthcare and are mentally prepared to offer a full scope of services to the rural constituency. To be effective, such a training should take place in rural health facilities, and the trainees should be embedded in rural communities.

Primary healthcare or a generalist approach

In rural areas, the health professionals need to provide a range of care, for a range of conditions to people across the life cycle. They therefore need to have a range of clinical skills, social skills, and leadership skills. Current medical and nursing education is conducted in specialized tertiary care settings and is geared toward providing care in such settings only.

In Queensland, medical education is geared toward a generalist approach that includes training in community-based primary medical practice, health facility–based secondary medical practice, and hospital- and community-based public health practice. In CMC Vellore, during the mandatory rural service, the medical graduates are offered a long-distance training in Family Medicine that equips them to provide primary healthcare in rural settings.

Social accountability mandate of medical and nursing schools

Social accountability of medical schools has been defined as “the obligation to direct their education, research, and service activities towards addressing the priority health concerns of the communities they serve.” Similar definition is relevant for nursing schools.

In the context of rural primary care, socially accountable medical or a nursing school would direct education, research, and services to address priority concerns of rural communities. A socially accountable rural medical school helped in addressing health needs of the populations of North Ontorio.

Availability of rural training sites

CMC Vellore has an affiliated group of about 200 secondary hospitals, largely in rural and remote areas that act as training sites for physicians and nurses. Training large numbers of doctors and nurses will require community-based rural training sites, public or private, where they can practice and learn primary and secondary healthcare, such as Bayalpata Hospital in Nepal. Experiences suggest that it is extremely helpful if the doctors and nurses in these facilities are accorded a faculty position.

Post-training support and placement

Evidence suggests that improved living and working conditions, better salaries, use of disruptive technology, co-operative arrangements with other rural health facilities, and continued training help the doctors and nurses to provide high-quality care in rural areas. In Nepal, the staff of the rural hospital at Bayalpata receive continued training and exchanges.

In the absence of adequate training, improvement in living and working conditions, and career progression, merely making it mandatory for nurses and doctors to work in rural areas does not work.

Recommendations for strengthening primary healthcare in rural India

Various experts and practitioners, based on their own experience and global evidence, made the following recommendations that would have relevance for strengthening primary healthcare in rural India.

Investments in primary healthcare

The policy commitment to invest 2.5% of GDP on healthcare and 70% of this expenditure on primary healthcare should be tracked periodically.

States that provide lower allocations on healthcare should be encouraged and supported to provide higher allocations.

Primary healthcare and PMJAY

PHCs and H and WCs should retain the gatekeeping function:

Patients should first present at PHCs, and only when referred by PHCs, should they be entitled for insurance cover under PMJAY for secondary or tertiary care. Such an arrangement would help in increasing utilization of PHCs and maintain the primacy of primary healthcare. It would also help in reducing expenditure by reducing unnecessary referrals

PMJAY should cover primary healthcare, in addition to the secondary and tertiary care:

It would help in promoting access to primary healthcare and also reduce the overall expenditure on healthcare, by reducing unnecessary referrals, by preventing illnesses, and by treating diseases at an earlier stage.

PHC team for health and wellness

Responsibility (and accountability) for care of a defined population should be entrusted to the entire primary healthcare team:

The team would consist of the PHC staff (including the primary care physician), and H and WC staff (consisting of the mid-level provider, auxiliary nurse midwife (ANMs), multipurpose worker (MPWs), and accredited social health activists (ASHAs)). Such a team is likely to provide comprehensive and continued care

Primary care physician should be trained in family medicine, and nurses (and other mid-level providers) should be trained in equivalent generalist care

Primary care team should be adequately supported through regular skilling, incentives, and supervision. Appropriate technological solutions should be provided to help them deliver quality healthcare

These teams should have functional linkages with higher levels of healthcare.

Creating and retaining healthcare professionals for rural primary healthcare (PHCs and H and WCs)

Revise undergraduate medical and nursing curriculum to align with rural priorities:

The training of MBBS should be aligned toward producing rural family physicians, and of nursing graduates, to produce rural primary care nurses

Currently, the graduate training of nurses and doctors has a heavy urban and tertiary healthcare bias

Allocate a large proportion of postgraduate seats for family-centered care with rural immersion:

In recent years, there has been a huge increase in postgraduate seats (MD/MS) for medical graduates. Allocating them to family medicine, with appropriate training in rural health care settings, will bring about the change in focus from tertiary care to primary care, and from urban bias to rural focus. It would require setting up family medicine programs in medical colleges, with strong rural focus

A similar shift can happen if large numbers of postgraduate seats for nurses are allocated to community health nursing, or nurse-practitioner program.

Make newly setup rural medical colleges responsible for district healthcare:

A large number of state-funded medical colleges are being set up in district hospitals, most of which are rural. Entrusting them with healthcare of their respective districts, focusing on sourcing rural students, adapting their training curricula to meet local needs, and helping them place within the districts would help them fulfil their social accountability. In such colleges, focus should be on primary and secondary care rather than tertiary care

Identify and accredit rural training sites for rural health professionals:

It would ensure sustained and high-quality training of a large number of professionals required for managing PHCs and H and WCs. The staff of these training sites should be accorded a faculty status.

Set up an empowered group to define improvements in training, living, and working conditions for rural healthcare professionals:

Such a group should be constituted of medical and nursing educationists from institutes that have a long experience of training doctors and nurses for rural areas, and practicing rural physicians and nurses.