What makes primary healthcare facilities functional, and increases the utilization? Learnings from 12 case studies

Background

The last few decades have witnessed a number of innovative approaches and initiatives to deliver primary healthcare (PHC) services in different parts of India. The lessons from these initiatives can be useful as India aims to strengthen the PHC system through Health and Wellness Centers (HWCs) component under Ayushman Bharat Program, launched in early 2018.

Materials and Methods

Comparative case study method was adopted to systematically document a few identified initiatives/models delivering the PHC services in India. Desk review was followed by field visits and key informant interviews. Twelve PHC case studies from 14 Indian states, with a focus on equity and "potentially replicable designs" were included from the government as well as the "not-for-profit" sector. The cases studies comprised of initiatives/models having the provision of PHC services, whether exclusively or as part of broader hospital services. The data was collected from May 2016 to March 2017.

Results

The "political will" for government facilities and "leadership and motivation" for "not-for-profit" facilities adjudged to contribute towards improved functioning. A comprehensive package of services, functional 'continuity of care' across levels, efforts to meet one or more type of quality standards and limited "intention to availability" gap (or assured provision of promised services) were considered to be associated with increased utilization. A total of 10 lessons and learnings derived from the analysis of these case studies have been summarised.

Conclusions

The case studies in this article highlights the components which makes PHC facilities functional and have potential for increased utilization. The article underscores the need for institutional mechanisms for health system research and innovation hubs at both national and state level in India, for the rapid scale of comprehensive primary healthcare. Lessons can be applied to other low- and middle-income countries intending to deliver comprehensive PHC services to advance towards universal health coverage.

National Medical Commission Act 2019: White paper on accelerated implementation of family medicine training programs towards strengthening of primary healthcare in India

Family medicine is the internationally recognized nomenclature for the academic discipline, knowledge domain, and medical specialty of primary care doctors, working in the community setting. Family medicine is defined as a specialty of medicine which is concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioral, and social sciences in the community setting. The distinction of family medicine lies in the tradition of medical generalism, promoting whole person care, in a life cycle mode; providing optimal preventive, promotive, and curative healthcare services in a wide spectrum of setting from home to hospital. In 2016, 92^nd report of the department-related parliamentary standing committee on health and family welfare on the "Functioning of the Medical Council of India" has emphasized the need for postgraduate in family medicine. The committee report has noted that "the medical education system is designed in a way that the concept of family physicians has been ignored. The committee recommends that the Government of India in coordination with State Governments should establish robust PG Programs in Family Medicine and facilitate introduction of Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care but also provide continuous healthcare for the individuals and families. The successive National Health Policies of Government of India-NHP 2002 and 2017 have emphasized the need of family medicine training in India. The recently enacted National Medical Commission Act 2019 has mandated NMC to promote training in family medicine at both undergraduate and postgraduate levels. Therefore, in the background of the stated policies of the Government of India the concept of family doctors, which was earlier neglected should be institutionalized within the mainstream medical education system of India. It is now time to accelerate and upgrade family medicine training and thereby strengthen the concept of comprehensive primary care in India. This white paper presents the review of family medicine training in India and proposes a way forward.

Basthi Dawakhana of Hyderabad: The first Urban Local Body led community clinics in India

Basthi Dawakhana initiative was launched by the Greater Hyderabad Municipal Corporation (GHMC) in Telangana state of India, in April 2018. This article documents, reviews, and analyzes the key design aspects of Basthi Dawakhana, delve into why such clinics are important for strengthening primary health care in Indian cities and urban settings, and proposes a few strategies for implementation effectiveness. In the main text of the article, evolution of urban health services, national urban health mission in India, and Mohalla clinics of Delhi has been provided. The implementation challenges and potetnial solutions for scaling up Basthi Dawakhana have been discussed. The author argues that Basthi Dawakhana initiative is aligned with the 73^rd and 74^th amendments in the Constitution of India, which transferred the responsibilities for primary care and public health to the Urban Local Bodies (ULBs). The article concludes that Basthi Dawakhana are arguably the first ULB-led community clinics initiative and an opportunities for ULBs in India to lead efforts to strengthen primary healthcare. These Dawakahna along with Mohalla Clinics, can serve platform to reform urban primary healthcare services and advance universal health coverage (UHC) in the country.