what reforms should India's Primary Health Care Needs quickly ?

The reality:

• The country spending  close to Rs 21,000 crore annually for NRHM. 
• primary healthcare can solve 90% of the medical problems.primary care is very effective at delivering effective individual interventions at routine consultations to prevent heart disease, stroke, and cancer.
• About 70%-80% (around 84 crore) of the population spend out-of-pocket on healthcare.
• health care spending is just  5% of GDP. Out of this the government  spending just 1.2% of the GDP on healthcare.
• there are 1.8 million child deaths and 68 000 maternal deaths in India each year and 52 million undernourished children.
•  Only 9  hospital beds per 10,000 people which  is far from adequate.
• insurance will pay for hospitalization, but not for outpatient treatment,which can affect cancer patients and it can affect follow-up care.
• “India still buys or imports most medical devices, and we still pay in dollars.
• Chronic diseases (such as heart disease, diabetes, cancer, and mental ill health) are already the leading cause of death and disability in India resulting in economical and social breakdown.
• substantial proportion of the population receive no treatment (47% of diabetics and 91% of those with angina in one survey).
• cost effective generic medicines are not always available in primary care; nor are they routinely used when they are available.

Lacunae and deficiencies of indian primary health care:
1. 72% of the population resides in rural geographies while 75% of the available medical infrastructure is based in urban settings.
2. transportation costs amount to as much as 80% of health-care costs. A critical part of a health-care delivery model is to reduce the number of referrals and thus impact these costs. 
3. Due to govt' s deficit budget, 10% of posts for doctors at the PHCs and 63% of the specialist posts at the CHCs, and 25% of the nursing posts at PHCs and CHCs combined remained unfilled. The situation for support staff is similar with 27% of pharmacist and 50% of laboratory technician posts also vacant.
4. absenteeism( up to a 50% absentee rate ), poor quality services, wastage, corruption, and weak management still characterize many of the community based primary healthcare institutions.

Target:

• Establishment of community health units each serving <5000 people and staffed by multidisciplinary teams (doctor, nurse, auxiliary nurse midwife, 4-6 community health workers).
• To provide affordable ,point of care vaccination, nutrition and hygiene support, safe maternity services, effective first contact acute care for serious disease.
• Primary care doctors making referral decisions on the basis of accurate diagnoses and managing most patients in the community according to evidence based guidelines using generic drugs.
• National target for infant mortality  <30/1000; 
• The child mortality rate age <5 years  38 /1000 live births.
• The maternal mortality ratio  <100/100 000 live births.
• The prevalence of underweight children 27% .
• Child immunization (for measles, polio, tetanus, diphtheria, pertussis, and tuberculosis ) coverage to be 100%.
• Adherence to oral rehydration for diarrhoea  to be 100%.

                                      Reforms:1. Multi-skilling - training individuals to perform tasks within their capacity but beyond their traditional professional roles, allows the available workforce in the team to be deployed most efficiently.

•  MOH and other social organizations should train and empower the  8 lac ASHA (Accredited Social Health Activists ) Workers in the country and make them identify early signs of a disease.
• Developing clinical and management skills in nurses and utilising their capacity beyond their existing roles.
• The existing Anganwadi child development (ICD) programme  should be strenthened to  improve vaccine uptake and breast feeding and for integrated nutritional and health advice—for children, pregnant women, and adults.

2. New technology -Electronic medical records, Mobile health & telemedicine to improve outreach to remote areas.

•  Application of IT: Diabetes,hypertension,asthma,anemia,vision and hearing abnormalities,skin lesions can be diagnosed and managed with the help of mobile phone and its applications and telemedicine and sustainable judicious supply of drug and vaccine chain.
• Technology assisted self care -for example, self-monitoring of blood pressure, blood coagulation (INR), and blood glucose, in reducing morbidity and mortality which will  also reduces healthcare workload and costs.
• Real time monitoring. using technology to allow real time monitoring or screening for a range of  chronic diseases.
• R&D partnership with the IT and health technology sector in India to develop innovative affordable technologies with very wide scale application.

3.promoting human resources:

• incentive schemes—monetary and non-monetary— to enhance recruitment of good doctors to rural areas.
• Establishing family medicine departments in every medical college and postgraduate training in primary care with the help of professional organisations like the Academy of Family Physicians of India and the College of General Practitioners of the Indian Medical Association.
• Preferential  admission to medical &nursing courses  should be given to local students from rural and underserved areas.
• Clinicians working in underserved areas should enjoy preference for postgraduate training, financial incentives, communication facilities, and opportunities for education of their children.
• Primary care  should be  recognized by the MCI as a specialty. primary care practitioners should have  formal postgraduate training and specialist accreditation and a o system for career progression. 
• remuneration for primary care should be  based in part on assessment of performance against evidence based, nationally agreed quality standards.      
• Generic drug usage :
• The proportion of medicines prescribed generically by each primary care centre should be  continuously monitored and used as a quality indicator linked to remuneration.

Good governance: 

•  Chronic illness (such as diabetes, asthma, hypertension, arthritis, depression, and heart failure) can be treated  mainly in primary care by creating good liasion system with the hospital specialist and Specialist involvement can be restricted to treating complications of problematic cases only.
• The most effective preventive strategies are dependent on legislation (for example, tobacco control and taxes.

Ideal PHC must have - thermometer, stethoscope, blood pressure measurement device, measurement tape, weighing machine, peak flow meter, spacers for inhalers, glucometer, blood glucose test strips, urine protein test strips, urine ketones test strips, WHO/ISH risk prediction charts, evidence based clinical protocols, flow charts with referral criteria, patient clinical record, medical information register, and audit tools. It can also adds, when resources permit: nebuliser, pulse oximeter, blood cholesterol assay, lipid profile test, serum creatinine assay, troponin test strips, urine microalbuminuria test strips, and ECG machine  (if training or support to read and interpret ECG  is available).