Context:

• National Health Policy 2017 has provided a concrete shape giving direction to health sector and has universal health coverage as its central goal. The need of strengthening Primary Health Care (PHC)system has been well Recognized.

Early Initiatives:

• In 2002, India had released second National Health Policy which was followed by National Rural Health Mission (NRHM) in 2005.
• The initiative under NRHM resulted in India eliminating polio, yaws and maternal and neonatal tetanus; reduced incidence of many communicable diseases and brought attention on strengthening PHC system.
• In 2017, that 15 years cycle seems to have been completed with new epidemiological realities, i.e. non-communicable diseases being the major burden of diseases and other health challenges.
• Understandably, the new third NHP 2017, followed by Ayushman Bharat Programme in 2018 as an implementation component addresses above Challenges.

Put Primary Health Care First:

• NHP 2017 has proposed to use Two-Third or more of government spending on PHC System.Indian states have an elaborate network of nearly 200,000 Government Primary Health Care Facilities, which deliver around 10% of total outpatient services (excluding mother and child health services).
• NHP 2017 proposed to increase overall utilization of Government health services from 30% to 50%. It is well known that PHC makes health services efficient; reduces the cost (both by people and government) and helps in increasing provision of preventive and promotive health services.
• Evidence points that the PHC system can tackle up to 80% of Health Needs and can reduce the need for specialized health services.

Stronger Health systems through Stronger PHC system:

• Re-design PHC system based upon available Local Evidence:a study of best performing PHC state identified certain characteristics in these facilities like,
• An assured package health services with ‘limited intention to availability gap’
• Appropriate mix and sufficient availability of Providers
• Continuous of care with functional Referral Linkages
• Initiatives to achieve Quality Standard
• Stronger local Level Leadership
• Community Engagement
• Correct ‘the inverted pyramid’ of Health Services Provision and Utilization:a large proportion of health services in India are delivered and used at secondary and tertiary level. Ideally, these services should be available at PHC level facilities. In short, the pattern of service utilization and delivery is inverted. This need to be corrected.
• Start Focused Initiatives to Tackle Social Determinants of health (SDH): a lot of determinants for better health – improved drinking water supply and sanitation; better nutritional outcomes, health and education for women and girls; improved air quality and safer roads.
• These issues are increasingly being recognized with emerging challenges such as Anti-microbial resistance (AMR), air pollution and non-communicable diseases (NCDs).
• There is need for multi-sectoral planning and ‘Health in all policies’ approach.  To tackle SDH is added under Ayushman Bharat Programme.
• Establish Sub-district Based Health System in India:Indian districts are on average 20 lakh population compared to 100,000 to 500,000 populations in other countries. These indicate effective planning of health services and tackling inequities in health outcomes need a sub-district unit level planning.
• Strengthen Urban Health Governance for Multi-Sectoral Collaboration:India has increasing urban population and is expected to reach 60 crore by 2030. The PHC system in urban areas need faster and effective interventions, if inverted pyramid of service delivery need to be tackled.
• Use of Behavioral Economics for better Health Outcomes:the Economic Survey has underscored the importance of behavioral economics (propounded by Nobel Laureate Richard Thaler). This has worked for Swachh Bharat Mission and Beti Bachao, Beti Padhao initiatives.
• In health, behavioral change ensure that people seek early care to prevent complications and late stage diseases and seek care at appropriate level, which will reduce burden from higher level of facilities.
• Focus on Public Health Cadre:dedicated cadres and workforce to deliver public health services like Public awareness and education about good nutrition, improved sanitation and health promoting behaviour should be created.

Conclusion:

• India is at a juncture, where it can build on past initiatives to transform health outcomes so as to have a healthy and prosperous nation, with minimal inequities.
• This would ensure that India achieves Universal Health Coverage as envisaged in the NHP 2017 as well as heath related SDGs.