Strengthening India's Primary Healthcare System

India's primary healthcare system is structured into a three-tier model: Sub-Centres (SCs), Primary Health Centres (PHCs), and Community Health Centres (CHCs), largely managed by state governments. Over the years, there have been significant governmental efforts to strengthen this backbone, most notably through:

• National Health Mission (NHM): This flagship program encompasses the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM), providing financial and technical support to states for strengthening their healthcare systems.

• Ayushman Bharat – Health and Wellness Centres (AB-HWCs): Launched in 2018, this initiative aims to transform existing SCs and PHCs into Health and Wellness Centres to provide comprehensive primary healthcare, including maternal and child health services, non-communicable disease (NCD) screening, and free essential drugs and diagnostics. As of March 31, 2023, India had 1,69,615 Sub-Centres, 31,882 PHCs, and 6,359 CHCs. The government aims to upgrade 1.5 lakh sub-centers to HWCs.

• Pradhan Mantri Jan Arogya Yojana (PM-JAY): While primarily focused on secondary and tertiary care hospitalization for economically vulnerable sections, its success indirectly reduces the burden on PHCs by providing an assured pathway for higher-level care.

• Jan Aushadhi Scheme: The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) aims to make quality generic medicines available at affordable prices. As of June 11, 2025, over 16,000 Janaushadhi Kendras are functional nationwide, offering medicines at 50-80% less than branded prices, leading to estimated savings of over ₹30,000 crores for citizens.

• Digital Health Initiatives: The Ayushman Bharat Digital Mission (ABDM) aims to create a seamless digital health ecosystem. Initiatives like eSanjeevani (national telemedicine service) have facilitated remote consultations, showing increasing adoption, though specific latest national figures for primary care telemedicine usage are still evolving. The National Tele Mental Health Programme launched in October 2022 has established 53 Tele MANAS Cells across 36 States/UTs as of January 20, 2025.

These initiatives have led to some positive trends, including a decline in Out-of-Pocket Expenditure (OOPE). According to National Health Accounts estimates for 2021-22, OOPE declined from 64.2% in 2013-14 to 39.4% in 2021-22, largely attributed to increased government investment (Government Health Expenditure as a percentage of GDP rose from 1.13% to 1.84% in the same period) and expansion of social security expenditure. The Economic Survey 2024-25 highlighted that total health spending reached ₹9.04 lakh crore in FY22 (3.8% of GDP), with the government's share increasing to 48% from 29% between FY15 and FY22.

Prevailing Gaps and Challenges

Despite the progress, significant gaps and challenges hinder the optimal functioning and equitable access to primary healthcare in India:

• Infrastructure and Accessibility Disparities:

  • Rural-Urban Divide: While urban areas boast multi-specialty hospitals, rural areas often lack adequate facilities. A PHC is intended to serve 30,000 people in general areas and 20,000 in difficult/tribal/hilly areas. However, a PHC on average serves approximately 36,000 people in rural areas compared to 9,000 in urban areas. This means, as of 2015 data, India was 16% below the required number of PHCs and approximately 50% below the number of CHCs.

  • Suboptimal HWC Functionality: While over 1.5 lakh HWCs are planned, a study in Eastern India (2024) highlighted that 75% of assessed HWCs operated in inadequate buildings lacking essential amenities. Critical services like neonatal/infant healthcare and childhood/adolescent care were offered by only 12.5% of the sampled HWCs.

• Critical Human Resource Shortages:

  • India faces a severe shortage of qualified healthcare professionals, particularly in rural areas. As of 2015 data, 8% of PHCs were without a doctor, 38% without a lab technician, and 22% without a pharmacist.

  • The situation at CHCs is even more dire, with 83% vacancy for surgeons, 76% for gynecologists/obstetricians, 83% for physicians, and 82% for pediatricians.

  • The overall vacancy rate for doctors at PHCs across India was 24% (as of 2011 data, older but indicative of persistent issues), with states like Chhattisgarh (71%), West Bengal (44%), and Maharashtra (37%) showing alarming figures. This leads to overburdened staff and compromised care quality.

• Affordability and Persistent Out-of-Pocket Expenditure (OOPE):

  • Despite the noted decline, OOPE at 39.4% in 2021-22 remains a substantial burden. For many households, medical expenses still lead to financial hardship, with studies indicating that healthcare expenditures can push families into debt or poverty.

  • The gap between public health spending (around 1.84% of GDP in 2021-22) and the target of 2.5% of GDP (National Health Policy 2017) means that many essential services still require significant out-of-pocket payments.

• Inconsistent Quality of Care:

  • Lack of proper diagnostic services at PHCs forces patients to seek care at higher-level facilities (like AIIMS or Safdarjung Hospital for basic ailments), leading to overcrowding and delayed specialized treatment.

  • Inadequate infrastructure, lack of essential equipment, and inconsistent availability of basic medicines affect the quality of care provided.

  • An assessment of HWCs showed that diagnostic capabilities were a challenge in 68.75% of centers, and crucial services like emergency medical services and mental health management had 0% availability.

• Low Health Awareness and Utilization:

  • Lack of awareness about available services, preventive measures, and when to seek care, especially in remote areas, leads to underutilization of PHCs for early intervention.

  • This often results in delayed treatment, progression of diseases, and higher costs associated with advanced care.

• Governance, Funding, and Implementation Gaps:

  • Despite increased allocations, efficient utilization and transparent distribution of funds remain a challenge.

  • Healthcare being a state subject means variations in implementation and outcomes across different states.

Policy Recommendations to Improve the Situation

To transform India's primary healthcare system into a robust, equitable, and accessible network, CPAR India proposes the following policy recommendations:

• Increase Public Health Spending to Target:

  • Recommendation: Expedite the increase in overall government health expenditure to at least 2.5% of GDP by 2025, as envisioned by the National Health Policy 2017.

  • Rationale: This will significantly reduce the burden of OOPE on households, enable better infrastructure development, and ensure universal access to essential services without financial hardship.

• Strengthen Infrastructure and Digital Integration:

  • Recommendation: Implement targeted investments to upgrade existing PHCs and CHCs, ensuring they meet the prescribed infrastructure and equipment standards, particularly in rural and remote areas.

  • Recommendation: Scale up telemedicine services (like eSanjeevani) and ensure last-mile connectivity. Equip HWCs with basic diagnostic capabilities and digital health records (under ABDM) to enable seamless patient information flow and remote consultations.

  • Rationale: This directly addresses the rural-urban divide and improves the quality and accessibility of diagnostic services at the primary level, reducing unnecessary referrals to tertiary care.

• Address Human Resource Shortages with Incentives and Training:

  • Recommendation: Implement attractive incentive packages (higher salaries, housing, career progression opportunities, hardship allowances) to attract and retain doctors, nurses, and paramedical staff in rural and underserved areas.

  • Recommendation: Expand medical and nursing education capacities, focusing on producing primary care physicians and community health workers. Mandate rural service for new medical graduates.

  • Recommendation: Provide continuous training programs for all primary healthcare staff, focusing on NCD management, mental health, geriatric care, and effective communication.

  • Rationale: A well-staffed and skilled workforce is fundamental to delivering quality PHC services and bridging the existing vacancies.

• Enhance Comprehensive Service Delivery:

  • Recommendation: Ensure a standardized package of comprehensive primary healthcare services at all HWCs, including preventive, promotive, curative, rehabilitative, and palliative care. This includes consistent availability of essential medicines and basic diagnostic tests.

  • Recommendation: Integrate AYUSH systems (Ayurveda, Yoga, Unani, Siddha, Homoeopathy) more effectively into the PHC framework for holistic wellness and broader acceptance, where appropriate.

  • Rationale: Moving beyond fragmented services to a truly comprehensive care model will improve health outcomes and build trust in the public health system.

• Fortify Preventive and Promotive Health Programs:

  • Recommendation: Launch sustained, large-scale health education and awareness campaigns using local languages and community leaders to improve health literacy, emphasize preventive measures, and promote early health-seeking behaviors.

  • Recommendation: Strengthen community-level initiatives focusing on sanitation, nutrition, maternal and child health, and immunization. Leverage the existing network of ASHA workers and Anganwadi Centres.

  • Rationale: Prevention is more cost-effective and impactful than cure. Empowering communities with health knowledge is crucial for long-term well-being.

• Improve Governance, Transparency, and Accountability:

  • Recommendation: Establish robust monitoring and evaluation frameworks with clear performance indicators for PHCs and HWCs. Utilize digital platforms for real-time data collection and analysis to identify and address bottlenecks.

  • Recommendation: Foster greater community participation in the planning and oversight of local health facilities through Village Health, Sanitation and Nutrition Committees (VHSNCs).

  • Rationale: Effective governance ensures optimal resource utilization, accountability, and responsiveness to community needs.

India's primary healthcare system is at a critical juncture. While significant strides have been made, persistent gaps in infrastructure, human resources, and quality of care, coupled with the enduring challenge of out-of-pocket expenditure, continue to impede the realization of universal health coverage. By strategically increasing public health spending, bolstering infrastructure, addressing workforce shortages, and prioritizing preventive care with robust governance, India can build a resilient and equitable primary healthcare system.