Primary health care – The way forward  

The World Health Organization (WHO) is celebrating 75 years of its founding today. It was established on 7^th April in 1948, a day which is commemorated annually as World Health Day. Since then, this global body has been spearheading the battle against several public health crises around the world, the most recent being the Covid-19 pandemic. The WHO has selected “Health for all” as the theme for the World Health Day this year.

It was in Alma Ata (in the then USSR) in 1978 at an international conference that 134 countries, including India, under the aegis of the WHO first set a goal of attaining health for all by the year 2000. The Alma Ata Declaration was a clarion call, which brought primary healthcare to the forefront and acknowledged it as the key towards attaining this goal, which later turned out to be rather an “ambitious” and “unrealistic” goal. This was a landmark step towards betterment of public health. This historic Declaration documented health as “a fundamental human right” and urged formulation of a national health policy for every member state. It also brought in the role of social and economic factors in health and well-being.

The social determinants of health or “the conditions in which people are born, grow, live, work and age” (WHO) are now increasingly being recognized as factors that influence health and health equity. These have been aptly called “the causes of the causes”. The 10 social determinants of health as defined by the WHO are: Social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport. It is not just the disease that needs to be treated, the socio-economic settings of the patient also need to be addressed.

The Millennium Declaration in 2000 proposed 8 Millennium Development Goals (MDGs) that aimed to eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empowerment for women, reduce childhood mortality, improve maternal health, combat HIV/AIDS, Malaria and other diseases, ensure environmental sustainability and develop global partnerships for development by the year 2015. 

In 2016, the 17 SDGs or the sustainable development goals supplanted the MDGs. These global goals are closely linked and relate not only to economic growth but also have social and environment dimensions. “Inclusivity”, “universality” and “leaving no one behind” are among the core principles of the 2030 Agenda for Sustainable Development. Universal health coverage is rooted in SDG 3.8, which aims to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.

These laid the foundation of the “one health” concept, which recognizes that the health of humans, plants, animals, plants and the environment is one. This is essential because zoonotic diseases are increasing.

The Astana Declaration in 2018 reaffirmed the commitment to primary health care as crucial to achieving universal health coverage. But its scope was more expansive. It talked of “empowering individuals and communities” to take care of their health under the guidance of doctors and “building sustainable primary health care”.

Despite several advances, inequity and inequality in health continue to exist. Healthcare is still inaccessible and unaffordable to many. The path upwards to secondary and tertiary care should begin from primary health care, which serves as the first point of contact for the patient and their families. Primary health care is not just curative; it is also preventive. According to the WHO, around “75% of the projected health gains from the SDGs could be achieved through PHC, including saving over 60 million lives and increasing average global life expectancy by 3.7 years by 2030”.

The WHO’s Thirteenth General Programme of Work (GPW 13) for 2019-2023 has defined triple billion targets (1 billion more people are benefiting from universal health coverage, 1 billion more people are better protected from health emergencies and 1 billion more people are enjoying better health and well-being) to be achieved by the end of this year. It remains to be seen if these targets were achieved.

The three dimensions of universal health care are coverage of population, health services and out-of-pocket expenditure. With the launch of the Ayushman Bharat scheme in 2018, India made a quantum leap towards universal healthcare coverage delivered via 1.5 lakh health and wellness centers. Achieving Universal Health Coverage is also a key guiding principle of the National Health Policy 2017. Another requisite towards this goal is a collaboration with the private sector, which caters to at least 80% of the healthcare needs of people.

“Health for all” requires greater commitment on the part of governments to spend more on health. According to the Economic Survey 2023, the expenditure in health sector in India in 2022-23 was 2.1% of the gross domestic product (GDP). The National Health Policy 2017 has envisaged increasing the governments health expenditure to 2.5% of GDP by 2025. As per the National Health Accounts (NHA) Estimates for India for 2018-19, government expenditure on primary healthcare has increased from 51.1% in 2013-14 to 55.2% in 2018-19. Primary and secondary care accounts for more than 80% of the current Government Health Expenditure. The result is a decline in out-of-pocket expenditure from 64.2% (2013-14) to 48.2% (2018-19). However, in the private sector, which delivers most of the healthcare today, the share of primary and secondary care has declined from 82% to 70% during the same period.

Alma Ata sowed the seeds of primary health care. Astana sought to make it more sustainable. Both recognised the pivotal role of primary health care in the progress towards health for all. Primary health care is still germane, especially in light of the Covid-19 pandemic, which has laid bare the gaps in the existing system.

If the goal of “Health for all” is to be realized, primary health care needs to be strengthened. The path towards universal health coverage is through a robust primary health care system.

About the Authors: Dr Sanjay Kalra, DM (AIIMS); President, SAFES, Bharti Hospital, Karnal, India; Dr Varun Arora, Professor, Dept. of Community Medicine, Pt BDS PGIMS, Rohtak, India, and; Dr. Madhur Verma, Assistant Professor, Dept. of Community & Family Medicine, AIIMS, Bathinda, Punjab