How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India

Abstract

IntroductionIn this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of ‘written’ policies in India—to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study.MethodsTo elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra—collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top–down and bottom–up lenses of the policy process.ResultsPrimary health centres were originally envisaged as ‘social models’ of service delivery; front-line institutions that delivered integrated care close to people’s homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors’ disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals.ConclusionsThis paper highlights some contextual complexities of implementing PHC—considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC—but cannot deliver on its ideals.

Sometimes Resigned, Sometimes Conflicted, and Mostly Risk Averse: Primary Care Doctors in India as Street Level Bureaucrats

“…This paper builds on a previously published paper that delineated broad contextual influences on primary health centers in India. 18 Located in peripheral areas, these centers are intended to deliver preventive as well as basic curative care in the public health system (see Box 1 for a detailed background). The quality of care delivered by such facilities, and indeed, similar facilities in other LMICs, has been lamented repeatedly.…”

Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa

“…Various researchers have examined the interplay between context and the role and characteristics of policy actors [27][28][29]. In Colombia, the implementation of HIV and AIDS policies were undermined by the lack of political will, the power of politicians at local government and corruption in resource distribution [30].…”

Community perspectives on primary health centers in rural Maharashtra: What can we learn for policy?

“…[567] These centers have been reduced to operationalizing a few national programs. [48] PHCs currently, do not get utilized as “frontline” institutions for basic curative care. Care for routine, “day-to-day” ailments in rural India is mostly sought by communities from the private sector; and often in the hands of informal (and sometimes untrained) health practitioners.…”