Anita Jain: A roundtable on primary healthcare in India

Coinciding with the visit of the British prime minister, David Cameron, to India last week, a business seminar was held in Mumbai to identify opportunities for health sector partnerships.

Meeta Lochan, secretary of the public health department of Maharashtra, offered insights on the intricacies of healthcare provisioning in Maharashtra. For instance, over the years the government has invested substantially in building health facilities so that nearly 60% of beds at the tertiary care level are now in the public health sector. However, less than 25% of doctors and medical equipment are in the public sector. Lack of data on the health outcomes of these investments further prevents effective planning for the future. To set standards for the quality of care in the nation, the Clinical Establishments (Registration and Regulation) Act came into force in 2010. However, implementation of the act has been sparse and very few states have adopted it so far.

I participated in the roundtable on public private partnership models for primary healthcare in India. This group included health professionals from the UK, CEOs of private hospitals in Mumbai, and Meeta Lochan who was representing the public health sector.

Across most major cities in India, there has been a recent growth in chains of private primary healthcare clinics working along similar lines to the NHS, with general practitioners serving as gatekeepers to secondary levels of care. Niti Pall from Pathfinder Health India shared her experience of setting up such an initiative in Delhi. She explained how the sustainability of such initiatives is difficult in the absence of a defined payer model. As a practising GP in the UK, she would manage nearly 80% of the patients who are seen in specialised hospitals in India. She emphasised, that what was essential was for the government to invest in primary healthcare services so that the majority of patients wouldn’t need to go to a hospital. This would thereby reduce the workload of hospitals, the burden and severity of diseases, and also healthcare costs.

While these clinics have largely sprung up in the urban centres of India, it will be vital to assess their feasibility in rural settings. As Meena Lochan shared, most positions for specialists lie vacant even in district hospitals—a grim indicator of the lack of motivation among doctors to practise in rural areas. Training locals to deliver healthcare along the lines of China’s barefoot doctors was recognised as a potential solution. However, initiatives to build a cadre of rural doctors through an abridged version of the MBBS programme, or to expand prescribing privileges to doctors from the traditional forms of Indian medicine, have faced stiff opposition from the Indian Medical Association.

Different provisioning models for primary healthcare services were discussed such as a hub-and-spoke model, tie-ups with multi-national companies as part of corporate social responsibility, employer sponsored memberships to these clinics, and telemedicine. While the need to innovate is recognised, it will be interesting to see how these models evolve over time and whether government investment may foster sustainability and uniformity. Provision of state sponsored insurance was also discussed as a possible payer mechanism, and is being implemented in some states of India. However, participation by private providers has been low and monitoring compliance with regulations have been stalling progress.

The discussions to find the right solution for primary healthcare in India made for a heady afternoon over coffee. As the Indian government considers different models towards the goal of universal health coverage, the world may well watch for the next big breakthrough.

Anita Jain is the India editor, BMJ.

  • Nice developments, but pardon my cynicism. I think there are major challenges to initiating and sustaining PPP’s for primary health care, especially in India. The comparison to PCTs of UK is hardly helpful. In the sort of regulatory environment that UK has and the magnitude and mechanisms of financing available in UK both render the comparisons futile.
    Secondly, an PPP’s operate in India under the assumption of “huge private sector”, “there is a market” etc. We all know that these markets fail in sectors like health, more so in primary health care, where equitable distribution is a concern. All the more in the Indian context where special efforts at primary health care are required given our caste, gender and socio-political arrangements. Will market-driven PPP’s be able to sustain this? Perhaps in very specific, engineered, well-regulated and value-driven conditions. Otherwise, I doubt it.

    And of course, over and above all this is the fact that health is shared between the states and the centre. As if the other inadequacies were not enough! Hmm…

  • Dr. Abhijeet Safai

    As per court judgement, a BAMS doctor can practice modern medicine in the state of Maharastra, India. Similar rules should be passed all over the India.


    bams is a course which is good example of blending traditional and modern medicine.The question is of maintaining good standards of education.Instead everybody is focused on protecting their own associations due to insecurity feeling; as IMA is doing.Government should scrutinize what is cross pathy and what is inter pathy.

  • Thanks for reading, and sharing your comment. Yes, I agree there is a need to revisit medical education in India so as to facilitate greater understanding of the different streams, and also appropriate utilization of the benefits each may offer in different disorders.

  • Thanks for reading and for sharing your comment. Being an allopathic doctor, I do also feel that greater appreciation is needed during undergraduate training of what Ayurveda has to offer so there can be better integration of what may be offered or recommended to patients.

  • Thanks for reading, and sharing your comment. I completely agree with you that given the unregulated nature of India’s private health sector, PPPs for provision of primary care under the larger tenet of universal health coverage are fraught with challenges. There are quite a few models that are being tested in different states, and may be worth evaluating how these go. While there may not be an immediate, one-size-fits all solution- these may definitely offer insights into improvising the right strategies and policies.
    Thanks again for sharing your views.

  • Dr. Abhijeet Safai

    Thanks a lot for replying. Saw the reply now. In the meanwhile, I was able to come across very important article about the core issue of BAMS education. Please find the link –

  • Aryan Dixit

    thanks for sharing the information, as the trend is going for online doctors , how to identify that is he having a real degrees or having fake one.

  • Medical education and awareness regarding healthcare policies is the safest way to find the right solution.

  • Nikhil Nanda

    Very well written post.
    I have written a piece too on affordability in primary healthcare in India.
    Do check it out.